Health inspection·June 26, 2025

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on medical record review and interview, the facility failed to provide restorative therapy as ordered and/or care planned. This affected four residents (Resident #77, Resident #78, Resident #79, and Resident #120) of four residents reviewed for therapy services. Facility census was 91. Findings include: 1. Review of the medical record for Resident #120 revealed an admission date of 09/18/24. Resident #120 was discharged on 05/28/25. Diagnoses included malignant neoplasm of the prostate, secondary malignant neoplasm of the bone, chronic kidney disease, stage four, dementia, dysphagia and history of falls. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/06/25, revealed Resident #120 had impaired cognition. Resident #120 required supervision for ambulation. Review of the plan of care dated 10/14/24 revealed Resident #120 was receiving Restorative Nursing Services (RNS) for ambulation baseline of 75-150 feet with contact guard assist (CGA), staff walking close to resident and front wheeled walker (FWW). Interventions included Resident #120 was to receive RNS up to six times a week for 15 minutes a day, and for staff to encourage Resident #120 to participate in the program to achieve goal. The goal was for Resident #120 to maintain ability through the next review as evidenced by continued ambulation of 75-150 feet with CGA and FWW. Review of physician orders for dated 01/14/25 indicated Resident #120 was to receive Restorative Nursing Services (RNS) for ambulation per restorative plan of care. Review of Resident #120's medical record revealed no evidence of restorative nursing services being completed per the plan of care. Interview on 06/23/25 at 2:28 P.M., Certified Nurse Assistant (CNA) #585 revealed Resident #120 was on the restorative program using two-pound weights for lower extremities and ambulation Monday through Friday. CNA #585 revealed she can't complete the therapy when she is pulled to work the floor. CNA #585 stated her being pulled has slowed down in the past two weeks, so she was able to complete her assignments. Interview on 06/23/25 at 4:07 P.M., the Director of Clinical Services (DCS) #701 revealed Resident #120 was not on a restorative therapy program, and therapy was not to assess until the next review period. Page 1 of 3 366428 366428 06/26/2025 O'Neill Healthcare Fairview Park 20770 Lorain Road Fairview Park, OH 44126

F 0688 Level of Harm - Minimal harm or potential for actual harm Interview on 06/25/25 at 9:15 A.M., Regional Administrator #700 and Administrator #601 confirmed the lack of evidence to show Resident #120 received restorative therapy. 2. Review of the medical record for Resident #77 revealed an admission date of 03/15/25. Diagnoses included malignant neoplasm of the stomach and type two diabetes mellitus. Residents Affected - Some Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/22/25, revealed Resident #77 had intact cognition. Resident #77 required maximum assistance for ambulation. Review of the plan of care dated 11/19/24 revealed Resident #77 received RNS ambulation program up to six days a week for 15 minutes a day. Resident #77 also received range of motion and strengthening exercises to maintain /improve strength in both lower extremities using a two-pound ankle weight when seated, two sets for 15 repetitions. Review of the facility restorative care flow record dated April, May and June 2025 revealed Resident #77 did not received therapy for ambulation or strengthening in April 2025, Resident #77 received restorative therapy for ambulation and strengthening three times in May 2025. Resident #77 received no restorative therapy for strengthening in June 2025, but did ambulate 10 times in June 2025. Interview on 06/24/25 at 2:47 P.M. with Resident #77 revealed staff have never used weights during restorative therapy sessions and therapy hasn't been provided in weeks. A family member present who visits throughout the week revealed therapy was not provided in weeks. Interview on 06/25/25 at 9:15 A.M., Regional Administrator #700 and Administrator #601 confirmed the lack of evidence to show Resident #77 received restorative therapy as care planned. 3. Review of the medical record for Resident #78 revealed an admission date of 08/17/25. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, difficulty in walking and foot drop, and unspecified foot. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/01/25, revealed Resident #78 had intact cognition. Resident #78 required substantial assistance for mobility. Review of the plan of care dated 04/11/25 revealed Resident #78 received RNS for range of motion, strengthening and transfer exercises six to seven times a week to maintain /improve strength in both lower extremities using a two-pound ankle weight when seated, two sets for 15 repetitions. Review of the facility restorative care flow record dated April, May and June 2025 revealed Resident #78 did not receive restorative therapy for strengthening in April 2025. Resident #78 received therapy for strengthening four times in May 2025 and no restorative therapy for strengthening in June 2025. The flow sheet for June 2025 indicated Resident #78 received assistance with ambulation two times in June. Interview on 06/24/25 at 2:51 P.M., Resident #78 she had not received therapy in months. Interview on 06/25/25 at 9:15 A.M., Regional Administrator #700 and Administrator #601 confirmed the lack of evidence to show Resident #78 received restorative therapy as care planned. 4. Review of the medical record for Resident #79 revealed an admission date of 02/15/25. Diagnoses 366428 Page 2 of 3 366428 06/26/2025 O'Neill Healthcare Fairview Park 20770 Lorain Road Fairview Park, OH 44126

F 0688 Level of Harm - Minimal harm or potential for actual harm included hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/01/25, revealed Resident #79 had impaired cognition. Resident #79 required substantial assistance for mobility. Residents Affected - Some Review of the plan of care dated 04/26/24 revealed Resident #79 received RNS for range of motion, strengthening and transfer exercises to six to seven times a week to maintain /improve strength in both lower extremities using a one-pound ankle weight when seated, two sets for 15 repetitions. Review of the facility restorative care flow record dated April, May and June 2025 revealed Resident #79 received one session of restorative therapy for strengthening/transfers in April 2025 and five times in May 2025. Resident #79 did not receive therapy for strengthening/transfers in June 2025. Interview on 06/24/25 at 2:39 P.M., Resident #79 stated she was not receiving restorative therapy like she should. Interview on 06/25/25 at 9:15 A.M., Regional Administrator #700 and Administrator #601 confirmed the lack of evidence to show Resident #79 received restorative therapy as care planned. This deficiency represents non-compliance investigated under Complaint Number OH00166104. 366428 Page 3 of 3