F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident record review, resident interview, staff interview and facility policy review, the facility failed to
ensure Resident #42 was treated with respect and dignity. This affected one resident (#42) of two residents
reviewed for respect and dignity. The facility census was 48.
Findings include:
Review of the medical record for Resident #42 revealed she was admitted to the facility on [DATE] with
diagnoses including Alzheimer's disease, dementia, schizophrenia, and schizoaffective disorder.
Review of the care plan dated 02/14/22, revealed Resident #42 behaved in a problematic manner
characterized by ineffective coping with paranoia and suspicious behaviors related to psychiatric illness.
Interventions included reassuring safety and talking in a low pitch, calm voice to decrease and/or eliminate
undesired behaviors and provide diversional activities.
Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 had a Brief
Interview for Mental Status (BIMS) score of three, indicating she had severe cognitive impairment. She was
independent with some setup assistance with activities of daily living (ADL). Review of the MDS
assessment revealed Resident #42 had a history of delusional thoughts.
Observation on 11/13/24 at 3:44 P.M. revealed Resident #42 approached the locked secured door adjacent
to the receptionist's desk and began knocking. Medical Secretary (MS) #562 got up from the seated
position, opened the door in a forceful manner, and approached Resident #42 stating in a rude, blunt tone
What do you want? Why are you knocking on the door that hard? Resident #42 was observed taking a step
back from the door and asked MS #562 a question that was unclear. MS #562 revealed she did not know
the answer to Resident #42's question, and Resident #42 turned and walked away.
Interview on 11/13/24 at 3:45 P.M. with MS #562, while turning her eyes upward, revealed she did not
always speak to residents in that manner, but Resident #42 was knocking on the door really hard. MS #562
confirmed and verified the interaction with Resident #42.
Interview on 11/13/24 at 3:46 P.M. was attempted with Resident #42, but she declined to speak.
Interview on 11/14/24 at 8:55 A.M. with Resident #42 revealed she was sometimes treated with respect and
dignity. Resident #42 revealed MS #562 was sometimes mean and rude when she approached her.
Review of the facility document titled Resident Rights and Dignity Policy, revised 2024, revealed
(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 8
Event ID:
366355
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
366355
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Singleton Health Care Center
1867 East 82nd Street
Cleveland, OH 44103
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 0550
the facility had a policy in place that residents would always be treated with courtesy and respect.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366355
If continuation sheet
Page 2 of 8
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
366355
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Singleton Health Care Center
1867 East 82nd Street
Cleveland, OH 44103
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 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, interview and facility policy review, the facility failed to ensure Resident #200's baseline care
plan was completed timely. This affected one resident (#200) of two residents reviewed for baseline care
plans. The facility census was 48.
Findings include:
Review of the medical record for Resident #200 revealed an admission date of 10/05/24 with diagnoses
including diabetes mellitus and malignant neoplasm of pancreas (cancer). Resident #200 was discharged
to the hospital on [DATE] and did not return to the facility.
Review of the baseline care plan in the electronic health record dated 10/07/24 revealed it was blank and
had not been completed.
Interview on 11/14/24 at 9:48 A.M. with Licensed Practical Nurse (LPN) #569 revealed she assisted in
completing the baseline care plans. She stated Resident #200 was admitted on [DATE] and was discharged
on 10/10/24. She stated she had initiated the baseline care plan, printed it out, and then began filling in the
information by hand on the form with information provided through staff interviews and observations. She
verified she had not completed the baseline care plan within 48 hours or entered it into the computer so
nursing staff had it available. LPN #569 verified the baseline care plan should have been in the computer
completed by 48 hours and reviewed with the resident and family.
Review of the facility policy titled, Baseline Care Plan, dated 11/28/17, revealed the baseline care plan
should be started on admission and completed within 48 consecutive hours of admission.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366355
If continuation sheet
Page 3 of 8
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
366355
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Singleton Health Care Center
1867 East 82nd Street
Cleveland, OH 44103
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** 2. Review of
the medical record for Resident #200 revealed an admission date of 10/05/24 with diagnoses including
diabetes mellitus and malignant neoplasm of pancreas (cancer). Resident #200 was discharged to the
hospital on [DATE] and did not return to the facility.
Review of the nursing admission observation dated 10/05/24 revealed Resident #200 needed a mechanical
Hoyer lift for transfers. He was dependent on staff for personal hygiene, including bed baths.
Review of the fall risk assessment dated [DATE] stated Resident #200 was at risk for falls as he was
disoriented and had decreased muscle coordination with jerking movements. It was noted that Resident
#200 did not have any falls in the past three months.
Review of the baseline care plan in the electronic health record dated 10/07/24 revealed it was blank and
had not been completed.
Review of the nursing progress note dated 10/07/24 at 6:32 A.M. for Resident #200 revealed he fell at
approximately 5:45 A.M. during care. Resident #200 was rolled on his side by the aide during bathing and
the resident fell out of bed. The resident had no injuries from the fall.
Review of the fall investigation dated 10/07/24 stated Resident #200 fell out of bed when Certified Nursing
Assistant (CNA) #523 rolled him onto his side during care. Resident #200 rolled off the bed and onto the
floor. The statement from CNA #523 verified he had rolled the resident onto his side, and the resident had
rolled off the bed onto the floor.
Review of the verbal warning by the DON to CNA #523 dated 10/09/24 revealed he was disciplined and
educated for giving care to a bed bound resident and leaving him in an unsafe position resulting in a fall.
Interview on 11/14/24 at 9:41 A.M. with the DON verified CNA #523 was providing care to Resident #200
on the morning of 10/07/24 and rolled him onto his side, and the resident rolled out of bed onto the floor in
between the wall and the bed. She stated CNA #523 was educated and provided a verbal warning because
he did not ensure the positioning of the bed against the wall and did not have two staff members while
providing care. She verified she was unsure if Resident #200 needed the assistance of two staff members
during bed mobility or bathing due to the baseline care plan not being completed timely.
Interview on 11/14/24 at 9:48 A.M. with LPN #569 revealed she assisted in completing the baseline care
plan for Resident #200. She stated Resident #200 was admitted on [DATE] and was discharged on
10/10/24. She stated she had initiated the baseline care plan, printed it out, and then began filling in the
information through staff interviews and observations. She verified she had not completed the baseline care
plan within 48 hours or placed it in the computer so that nursing staff had it available. LPN #569 verified the
baseline care plan should have been completed and entered into the computer within 48 hours of
admission and reviewed with the resident and family. She also verified there were no interventions to assist
in preventing falls for Resident #200.
Attempted interviews on 11/14/24 at 10:59 A.M. and 2:15 P.M. with CNA #523 were unsuccessful.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366355
If continuation sheet
Page 4 of 8
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
366355
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Singleton Health Care Center
1867 East 82nd Street
Cleveland, OH 44103
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
Voicemail messages were left and were not returned.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility policy titled, Baseline Care Plan, dated 11/28/17, revealed the baseline care plan
should be started on admission and completed within 48 consecutive hours of admission.
Residents Affected - Few
Based on record review, interviews and facility policy review, the facility failed to ensure fall prevention
interventions were documented on the Kardex, failed to ensure an accurate falls risk assessment, and
failed to do post fall assessments for 72 hours according to the facility policy for Resident #34. In addition,
the facility failed to ensure safety of Resident #200 during care. This affected two residents (#34 and #200)
of two residents reviewed for accidents. The facility census was 48.
Findings include:
1. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with
diagnoses including epilepsy, hypertension, bradycardia, conversion disorder with seizures, cognitive
communication deficit, dementia with behaviors, schizophrenia, cardiomyopathy, congestive heart failure,
and vitamin B12 deficiency.
Review of Resident #34's medication orders for July 2024 through September 2024 revealed orders for
Norvasc, Losartan Potassium, Metoprolol Succinate ER (antihypertensives), Torsemide, hydralazine HCL,
Furosemide, spironolactone (diuretics) and Depakote ER and Keppra (anti-seizure medications).
Review of the fall incident description dated 09/29/24 at 6:07 P.M. revealed Resident #34 was in his room
with a Certified Nurse Aide (CNA) present, and he tripped over a book bag that was kept underneath his
bed. Resident #34 was observed on floor on all fours and was assessed by the nurse and had no injuries.
He was educated to educated to keep the walkway free of clutter.
Review of medical record dated 09/29/24 to 10/01/24 revealed the facility failed to assess Resident #34
every shift post fall for 72 hours according to their policy.
Review of the Medication Administration Record (MAR) for September 2024 revealed Resident #34 had
been receiving the antihypertensives, antiseizure and diuretic medications as ordered.
Review of the fall risk assessment dated [DATE] for Resident #34 revealed under section G. Medications,
the resident took only one to two of the following medications in the last seven days: anesthetics,
antihistamines, antiseizure, antihypertensives, benzodiazepines, cathartics, diuretics, hypoglycemics,
narcotics, psychoactives, sedatives/hypnotics. Further review revealed under section H. Predisposing
diseases included CVA, Parkinson's disease, seizures, arthritis, loss of limb, arthritis, osteoporosis,
fractures, multiple sclerosis, vertigo and hypotension, and the assessment indicated Resident #34 had
none of the predisposing diseases.
Review of the plan of care, dated 10/07/24, revealed Resident #34 had a risk for falls related to seizure
disorder. An intervention included to ensure the floor was free of clutter.
Review of Resident #34's current Kardex revealed the intervention dated 10/07/24 to ensure the resident's
floor remained free of clutter had not been added.
Interview with the Director of Nursing (DON) on 11/13/24 at 1:35 P.M. confirmed the new fall
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366355
If continuation sheet
Page 5 of 8
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
366355
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Singleton Health Care Center
1867 East 82nd Street
Cleveland, OH 44103
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
intervention dated 10/07/24 ensure floor remain free of clutter was not on the Kardex.
Level of Harm - Minimal harm
or potential for actual harm
Interview with CNA #524 on 11/14/24 at 9:28 A.M. revealed that she refers to the Kardex or will ask the
nurse regarding any changes or updates to a resident's care.
Residents Affected - Few
Interview with Minimum Data Set 3.0 (MDS) Licensed Practical Nurse (LPN) #569 on 11/13/24 at 1:42 P.M.
confirmed incorrect documentation was identified on the falls risk assessment dated [DATE] based on the
record review pertaining to the medications and predisposing diseases.
Interview with the Director of Nursing (DON) on 11/13/24 at 2:53 P.M. confirmed that nursing
documentation was not completed on every shift for 72 hours per Singleton Health Care Post Fall Protocol,
dated 12/01/2016.
Review of the facility policy titled, Singleton Health Care Post Fall Protocol, dated 12/01/16, revealed the
MDS Coordinator would complete a fall risk assessment after the fall and add new interventions to the
resident's fall risk care plan.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366355
If continuation sheet
Page 6 of 8
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
366355
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Singleton Health Care Center
1867 East 82nd Street
Cleveland, OH 44103
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to ensure pharmacy recommendations were followed up on
for Resident #1. This affected one resident (Residents #1) of five residents reviewed for unnecessary
medications. The facility census was 48.
Findings include:
Review of the medical record for Resident #1 revealed an admission date of 09/18/19 with diagnoses
including arthritis, schizophrenia and insomnia.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was
cognitively intact. She required set up assistance for eating and oral hygiene and substantial or maximum
assistance for dressing, toileting, showering and personal hygiene.
Review of the Medication Administration Record (MAR) for July 2024 revealed an order for Haldol (an
antipsychotic medication) 0.5 milligrams (mg) intramuscularly (IM) every six hours as needed (prn). The
order began on 07/22/24 and was discontinued on 08/29/24.
Review of the document titled Note to Attending Physician/Prescriber dated 07/18/24 revealed pharmacist
#570 requested Medical Director (MD) #571 to consider adding an end date of 08/05/24 to Haldol IM 0.5
mg. There was no evidence MD #572 addressed the recommendation.
Interview on 11/14/24 at 10:36 A.M. with the Director of Nursing confirmed the recommendation by
Pharmacist #570 for Resident #1 dated 07/18/24 was not addressed by MD #572 regarding the end date of
08/05/24 for the Haldol.
Review of the facility policy titled Medication Monitoring dated 06/21/17 revealed residents who received
psychotropic medications would receive gradual dose reductions unless clinically contraindicated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366355
If continuation sheet
Page 7 of 8
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
366355
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Singleton Health Care Center
1867 East 82nd Street
Cleveland, OH 44103
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 - Few
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
interview and record review, the facility failed to ensure fall risk assessments were documented accurately
for Resident #34 who was at risk of falls. This affected one resident (Resident #34) of three residents
reviewed for falls. The facility census was 48.
Findings include:
Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses
including epilepsy, hypertension, bradycardia, conversion disorder with seizures, cognitive communication
deficit, dementia with behaviors, schizophrenia, cardiomyopathy, congestive heart failure, and vitamin B12
deficiency.
Review of Resident #34's medication orders for July 2024 through September 2024 revealed orders for
Norvasc, Losartan Potassium, Metoprolol Succinate ER (antihypertensives), Torsemide, hydralazine HCL,
Furosemide, spironolactone (diuretics) and Depakote ER and Keppra (anti-seizure medications).
Review of the fall risk assessments dated 07/05/24 and 10/02/24 for Resident #34 revealed under section
G. Medications, the resident took only one to two of the following medications in the last seven days:
anesthetics, antihistamines, antiseizure, antihypertensives, benzodiazepines, cathartics, diuretics,
hypoglycemics, narcotics, psychoactives, sedatives/hypnotics.
Review of the Medication Administration Record (MAR) for September 2024 revealed Resident #34 had
been receiving the antihypertensives, antiseizure and diuretic medications as ordered.
Further review of the fall risk assessments dated 07/05/24 and 10/02/24 revealed under section H.
Predisposing diseases included CVA, Parkinson's disease, seizures, arthritis, loss of limb, arthritis,
osteoporosis, fractures, multiple sclerosis, vertigo and hypotension, and the assessment indicated Resident
#34 had none of the predisposing diseases.
Interview with Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #569 on 11/13/24 at 1:42 P.M.
confirmed that incorrect documentation was identified on the falls risk assessments dated 10/2/24 and
07/05/24. LPN #569 confirmed that each of the assessments had identical documentation that was
incorrect based on the record review pertaining to the medications and predisposing diseases.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366355
If continuation sheet
Page 8 of 8