Inspection visit
Inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
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 facility policy review, the facility failed to ensure Resident #76 had
access to a call light within their functional abilities. This affected one resident (#76) of three reviewed for
call light accessibility and had the potential to affect six residents (#18, #21, #27, #61, #74 and #76)
identified by the facility as using a modified call light. The facility census was 93.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #76 revealed and admission date of 11/17/23. Diagnoses
included Multiple Sclerosis, paralysis of the left side, tremors, and depression.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76
was cognitively intact. She required partial to moderate assistance for eating and oral care and substantial
or maximum assistance for toileting, showering, and personal hygiene.
Review of the care plan dated 02/26/25 revealed Resident #76 who is at risk for a self-care deficit.
Interventions included considering the need for assistive devices and determining factors that hindered the
residents' limitations for movement, and encourage the resident to use the call light for staff assistance.
Interview on 03/05/25 at 8:57 A.M. with Resident #76 revealed she had a call light pad lying on her chest.
She revealed she could not push the pad. Observation at the time of the interview with Certified Nursing
Assistant (CNA) #203 revealed Resident #76 could not touch the call pad with her hand. CNA #203 moved
to the pad closer to Resident #76 and attempted to assist her in touching the call light pad. CNA #203
confirmed Resident #76 could not activate the call light to call for assistance. She said Resident #76 used
the call light in the past; however, there was no documented evidence that she was able to use it. The
Administrator stated she was going to place an order for an occupation therapy (OT) evaluation to
determine an appropriate call light for Resident #76.
Interview on 03/6/25 at 9:59 A.M. with the Administrator revealed she had no knowledge of Resident #76
being unable to use the call light pad.
Review of the facility policy titled Resident Call System, dated March 2023, revealed the facility would
provide an environment which assisted in meeting the residents' needs, including responding to call lights.
This deficiency represents noncompliance investigated under Complaint Number OH00161454.
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 9
Event ID:
366491
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
366491
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Strongsville Healthcare and Rehabilitation
18936 Pearl Road
Strongsville, OH 44136
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, interview and facility policy review, the facility failed to ensure Residents #6, #74, and #76
received showers on a consistent basis. This affected three residents (#6, #74 and #76) of three residents
reviewed for showers and had the potential to affect all residents. The facility identified all residents required
assistance with showers. The facility census was 93.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #6 revealed an admission date of 02/19/25. Diagnoses
included cancer of the urinary system, weakness, and hypertension.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident
#6 was severely cognitively impaired. He required setup help for eating, supervision for oral and personal
hygiene, partial to moderate assistance for showering and was dependent for toileting.
Review of the shower sheets dated 02/02/25 through 03/03/25 revealed Resident #6 received a bed bath
on 02/20/25, 02/27/25, and 03/3/25. He refused a shower on 02/24/25 but requested a bed bath.
Interview on 03/05/25 at 10:09 A.M. with Resident #6 and his son revealed Resident #6 had not received a
shower since his admission to the facility; he only received bed baths. Resident #6's son revealed he would
like to see his dad receive a shower one to two times a week; Resident #6 nodded in agreement.
2. Review of the medical record for Resident #74 revealed an admission date of 07/12/23. Diagnoses
included stroke, paralysis, hypertension, and muscle weakness.
Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #74 was moderately
cognitively impaired. He required partial to moderate help for eating, oral and personal hygiene and
substantial to maximum assistance for toileting, showering, and dressing.
Review of the shower sheets dated 01/07/25 through 02/28/25 revealed Resident #74 received a bed bath
on 01/07/25 and a shower on 02/14/25. He refused a shower on 02/04/25 and 02/28/25.
Review of the certified nursing assistant (CNA) shower tasks dated 02/04/25 through 03/05/25 revealed
Resident #74 received a shower on 02/04/25, 02/18/25 and 02/22/25. (The shower sheet stated Resident
#74 refused a shower on 02/04/25).
3. Review of the medical record for Resident #76 revealed and admission date of 11/17/23. Diagnoses
included multiple sclerosis, paralysis of the left side, tremors, and depression.
Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #76 was cognitively intact.
She required partial to moderate assistance for eating and oral care and substantial or maximum
assistance for toileting, showering and personal hygiene.
Review of the shower sheets dated 02/04/25 through 03/04/25 revealed Resident #76 received a bed bath
02/04/25 and 02/25/25 and a shower on 02/07/25, 02/21/25, 02/28/25, 03/04/25. She refused a shower on
02/11/25.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366491
If continuation sheet
Page 2 of 9
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
366491
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Strongsville Healthcare and Rehabilitation
18936 Pearl Road
Strongsville, OH 44136
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the CNA shower tasks dated 02/07/25 through 03/04/25 revealed Resident #76 received a
shower on 02/07/25, 02/11/25, 02/14/25, 02/18/25, 02/28/25 and 03/04/25. (The shower sheet stated
Resident #76 refused a shower on 02/11/25).
Interview on 03/05/25 at 8:57 A.M. with Resident #76 revealed she was given a shower less than once per
week. She preferred a shower, not a bed bath.
Interview on 03/05/25 at 9:02 A.M. with CNA #203 revealed most residents were supposed to receive a
shower at least twice per week; she confirmed showers were not always provided consistently.
Interview on 03/06/25 at 11:12 A.M. with the Director of Nursing (DON) confirmed information on resident
shower sheets and CNA tasks was inconsistent. She could not confirm which information was accurate.
Review of the facility policy titled Bathing-Personal Care, dated August 2024, revealed residents would be
offered a shower or bath twice a week and as needed.
This deficiency represents noncompliance investigated under Complaint Number OH00161454.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366491
If continuation sheet
Page 3 of 9
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
366491
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Strongsville Healthcare and Rehabilitation
18936 Pearl Road
Strongsville, OH 44136
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 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 call lights were answered in a timely
manner. This affected five residents (#1, #8, #34, #49 and #82) of six residents reviewed for timely call light
response. The facility census was 93.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #1 revealed an admission date of 12/28/22 and a discharge
date of 03/05/25. Diagnoses included cellulitis, right below the knee amputation, generalized muscle
weakness, difficulty walking, diabetes, and chronic pain.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident
#1 was cognitively intact. He was continent of bowel and bladder, independent in eating, oral and personal
hygiene, and required supervision for toileting and showering.
Review of the fall risk assessment dated [DATE] revealed Resident #1 was not at risk for falls.
Observation and interview on 03/05/25 at 1:09 P.M. with Registered Nurse (RN) #207 revealed the
activated call light system indicated which call lights had been activated and how long they remained
unanswered. She confirmed Resident #1's call light had remained unanswered for 19 minutes. She
revealed all call lights should be answered in less than 15 minutes.
2. Review of the medical record for Resident #8 revealed and admission date of 12/06/23. Diagnoses
included morbid obesity, heart failure, respiratory failure, weakness, difficulty walking, and lack of
coordination.
Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #8 was moderately
cognitively impaired. He was incontinent of bowel and bladder, required setup help for eating, supervision
for oral and personal hygiene, substantial or maximum assistance for showering, and was dependent on
staff for toileting.
Review of the fall risk assessment dated [DATE] revealed Resident #8 was at risk for falls.
Observation and interview on 03/05/25 at 1:09 P.M. with RN #207 revealed the activated call light system
indicated which call lights had been activated and how long they remained unanswered. She confirmed
Resident #8's call light had remained unanswered for 49 minutes. She stated all call lights should be
answered in less than 15 minutes.
3. Review of the medical record for Resident #34 revealed an admission date of 09/23/23. Diagnoses
included heart disease, irritable bowel syndrome, constipation, and macular degeneration.
Review of the quarterly MDS 3.0 assessment data 12/31/24 revealed Resident #34 was moderately
cognitively impaired. She was frequently incontinent of bowel and bladder, required setup help for eating
and partial to moderate assistance for oral hygiene, toileting, showering, dressing and personal hygiene.
Review of the fall risk assessment dated [DATE] revealed Resident #34 was at risk for falls.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366491
If continuation sheet
Page 4 of 9
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
366491
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Strongsville Healthcare and Rehabilitation
18936 Pearl Road
Strongsville, OH 44136
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Observation on 03/05/25 at 10:03 A.M. revealed Resident #34's call light had been activated. Certified
Nursing Assistant (CNA) #204 answered Resident #34''s call light after 21 minutes. Interview at the time of
the observation with CNA #204 confirmed the activated call light system revealed Resident #34's call light
remained unanswered for 21 minutes. CNA #204 revealed call lights should be answered as soon as
possible, but within approximately five minutes.
Residents Affected - Few
4. Review of the medical record for Resident #49 revealed an admission date of 09/30/22. Diagnoses
included dementia, repeated falls, heart failure, depression, difficulty walking, and weakness.
Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #49 was severely cognitively
impaired. She was always incontinent of bladder and required setup help for eating, partial to moderate
assistance for toileting and showering, and substantial to maximal assistance for oral and personal hygiene.
Observation and interview on 03/05/25 at 1:09 P.M. with RN #207 revealed the activated call light system
indicated which call lights had been activated and how long they remained unanswered. She confirmed
Resident #49's call light had remained unanswered for 47 minutes. She stated all call lights should be
answered in less than 15 minutes.
5. Review of the medical record for Resident #82 revealed and admission date of 02/02/33. Diagnoses
included arthritis, difficulty walking, muscle weakness, hypothyroidism, osteoporosis, depression, cataracts,
repeated falls, and artificial knee joints.
Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #82 was cognitively
intact. She was frequently incontinent of bladder and occasionally incontinent of bowel. She required partial
to moderate assistance for eating and toileting and supervision or touch assistance for showering and
personal hygiene.
Review of the fall risk assessment dated [DATE] revealed Resident #82 was at risk for falls.
Observation on 03/05/25 at 8:57 A.M. revealed Resident #82's call light had been activated for 24 minutes.
At 9:06 A.M. an unknown aide entered Resident #82's room and assisted her out of her room and down the
hall. Observation of the activated call light system confirmed Resident #82's call light remained unanswered
for 33 minutes.
Interview on 03/06/25 at 8:13 A.M. with the Administrator confirmed the expectation was for call lights to be
answered in approximately 10 minutes.
Review of the facility policy titled Resident call system dated March 2023 revealed resident call lights would
be responded to in a timely manner.
This deficiency represents noncompliance investigated under Complaint Number OH00161454.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366491
If continuation sheet
Page 5 of 9
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
366491
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Strongsville Healthcare and Rehabilitation
18936 Pearl Road
Strongsville, OH 44136
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, interview and review of the facility's' payroll-based journal (PBJ) data, the facility
failed to ensure sufficient staffing to meet the needs of residents. This affected seven residents (#1, #6, #8,
#34, #49, #76, #82) of eight residents reviewed for sufficient staffing and had the potential to affect all
residents. The facility census was 93.
Findings include:
1. Review of the medical record for Resident #1 revealed an admission date of 12/28/22 and a discharge
date of 03/05/25. Diagnoses included cellulitis, right below the knee amputation, generalized muscle
weakness, difficulty walking, diabetes and chronic pain.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident
#1 was cognitively intact. He was continent of bowel and bladder, independent in eating, oral and personal
hygiene and required supervision for toileting and showering.
Review of the fall risk assessment dated [DATE] revealed Resident #1 was not at risk for falls.
Observation and interview on 03/05/25 at 1:09 P.M. with Registered Nurse (RN) #207 revealed the
activated call light system indicated which call lights had been activated and how long they remained
unanswered. She confirmed Resident #1's call light had remained unanswered for 19 minutes. She
revealed all call lights should be answered in less than 15 minutes. She confirmed there was not enough
staff to complete all daily tasks, including showers and answering call lights timely.
2. Review of the medical record for Resident #6 revealed an admission date of 02/19/25. Diagnoses
included cancer of the urinary system, weakness and hypertension.
Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #6 was severely
cognitively impaired. He was always incontinent of bowel and bladder and required setup help for eating,
supervision for oral and personal hygiene, partial to moderate assistance for showering and was dependent
on staff for toileting.
Review of the fall risk assessment dated [DATE] revealed Resident #6 was at risk for falls.
Review of the shower sheets dated 02/02/25 through 03/03/25 revealed Resident #6 received a bed bath
on 02/20/25, 02/27/25, and 03/3/25. He refused a shower on 02/24/25 but requested a bed bath.
Interview on 03/05/25 at 9:02 A.M. with Certified Nursing Assistant (CNA) #203 revealed most residents
were supposed to receive a shower at least twice per week; she confirmed showers were not always
provided consistently.
Interview on 03/05/25 at 10:09 A.M. with Resident #6 and his son revealed Resident #6 had not received a
shower since his admission to the facility; he only received bed baths, and it often took staff hours to
respond to Resident #6's call light. He felt these issues were due to a lack of staff availability.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366491
If continuation sheet
Page 6 of 9
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
366491
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Strongsville Healthcare and Rehabilitation
18936 Pearl Road
Strongsville, OH 44136
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
3. Review of the medical record for Resident #34 revealed an admission date of 09/23/23. Diagnoses
included heart disease, irritable bowel syndrome, constipation and macular degeneration.
Review of the quarterly MDS assessment data 12/31/24 revealed resident #34 was moderately cognitively
impaired. She was frequently incontinent of bowel and bladder, required setup help for eating and partial to
moderate assistance for oral hygiene, toileting, showering, dressing and personal hygiene.
Review of the fall risk assessment dated [DATE] revealed Resident #34 was at risk for falls.
Observation on 03/05/25 at 10:03 A.M. revealed resident #34's call light had been activated. CNA #204
answered Resident #34's call light after 21 minutes. Interview at the time of the observation with CNA #204
confirmed the activated call light system revealed Resident #34's call light remained unanswered for 21
minutes. CNA #204 revealed call lights should be answered as soon as possible, but within approximately
five minutes. CNA #204 revealed it was especially difficult to respond to call lights during mealtime due to
lack of staffing.
4. Review of the medical record for Resident #8 revealed and admission date of 12/06/23. Diagnoses
included morbid obesity, heart failure, respiratory failure, weakness, difficulty walking and lack of
coordination.
Review of the comprehensive MDS assessment dated [DATE] revealed Resident #8 was moderately
cognitively impaired. He was incontinent of bowel and bladder, required set of help for eating, supervision
for oral and personal hygiene, substantial or maximum assistance for showering almost dependent for
toileting.
Review of the fall risk assessment dated [DATE] revealed resident #8 was at risk for falls.
Observation and interview on 03/05/25 at 1:09 P.M. with RN #207 revealed the activated call light system
indicated which call lights had been activated and how long they remained unanswered. She confirmed
Resident #8's call light had remained unanswered for 49 minutes. She stated all call lights should be
answered in less than 15 minutes. She confirmed there was not enough staff to complete all daily tasks,
including showers and answering call lights timely.
5. Review of the medical record for Resident #49 revealed an admission date of 09/30/22. Diagnoses
included dementia, repeated falls, heart failure, depression, difficulty walking and weakness.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #49 was severely cognitively
impaired. She was always incontinent of bladder and required setup help for eating, partial to moderate
assistance for toileting and showering and substantial to maximal assistance for oral and personal hygiene.
Review of the fall risk assessment dated [DATE] revealed Resident #49 was at risk for falls.
Observation and interview on 03/05/25 at 1:09 P.M. with RN #207 revealed the activated call light system
indicated which call lights had been activated and how long they remained unanswered. She confirmed
Resident #49's call light had remained unanswered for 47 minutes. She stated all call lights should be
answered in less than 15 minutes. She confirmed there was not enough staff to complete all daily tasks,
including showers and answering call lights timely.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366491
If continuation sheet
Page 7 of 9
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
366491
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Strongsville Healthcare and Rehabilitation
18936 Pearl Road
Strongsville, OH 44136
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
6. Review of the medical record for Resident #76 revealed an admission date of 11/17/23. Diagnoses
included multiple sclerosis, paralysis of the left side, tremors and depression.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #76 was cognitively intact. She
was always incontinent of bowel and bladder and required partial to moderate assistance for eating and
oral care and substantial or maximum assistance for toileting, showering and personal hygiene.
Review of the fall risk assessment dated [DATE] revealed Resident #76 was not at risk for falls.
Interview on 03/05/25 at 8:57 A.M. with Resident #76 revealed she was given a shower less than once per
week. She preferred a shower, not a bed bath.
Interview on 03/05/25 at 9:02 A.M. with CNA #203 revealed most residents were supposed to receive a
shower at least twice per week; she confirmed showers were not always provided consistently.
Interview on 03/05/25 at 1:00 P.M. with CNA #203 confirmed she had written on the shower sheet for
Resident #76 on 02/04/25 she could not complete four showers. (The shower sheet did not specify the
other three residents affected). She stated it was due to lack of staffing.
Interview on 03/05/25 at 1:09 P.M. with RN #207 revealed she was informed by CNA #203 on 02/04/25 she
could not complete a shower for Resident #76, and agreed there were times showers were not completed
due to lack of staff.
Review of the shower sheets dated 02/04/25 through 03/04/25 revealed Resident #76 received a bed bath
02/04/25 and 02/25/25 and a shower on 02/07/25, 02/21/25, 02/28/25, 03/04/25. She refused a shower on
02/11/25.
Review of the CNA shower tasks dated 02/07/25 through 03/04/25 revealed Resident #76 received a bed
bath or shower on 02/07/25, 02/11/25, 02/14/25, 02/18/25, 02/28/25 and 03/04/25. (The shower sheets
stated Resident #76 refused a shower on 02/11/25).
Interview on 03/06/25 at 11:12 A.M. with the Director of Nursing (DON) confirmed information on resident
shower sheets and CNA tasks was inconsistent. She could not confirm which information was accurate.
7. Review of the medical record for Resident #82 revealed an admission date of 12/06/23 with diagnoses
including unspecified injury of the head, hypoventilation, heart failure, hypoxia, and malnutrition.
Review of the comprehensive MDS assessment dated [DATE] revealed Resident #82 was cognitively intact.
She was frequently incontinent of bladder and occasionally incontinent of bowel. She required partial to
moderate assistance for eating and toileting and supervision or touch assistance for showering and
personal hygiene.
Review of the fall risk assessment dated [DATE] revealed Resident #82 was at risk for falls.
Observation on 03/05/25 at 8:57 A.M. revealed Resident #82's call light had been activated for 24 minutes.
At 9:06 A.M. an unknown aide entered Resident #82's room and assisted her out of her room and down the
hall. Observation of the activated call light system confirmed Resident #82's call light
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366491
If continuation sheet
Page 8 of 9
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
366491
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Strongsville Healthcare and Rehabilitation
18936 Pearl Road
Strongsville, OH 44136
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 0725
remained unanswered for 33 minutes.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 03/05/25 at 2:00 P.M. with Residents #82 and #85 (present for the interview with Resident #82)
revealed call response was quite lengthy most of the time, and Resident #85 believed they did not have
enough staff, which she attributed to the long call response.
Residents Affected - Some
8. Review of the PBJ data submitted by the facility for the fourth quarter of 2024 (July 1 - September 30),
revealed the facility had a one-star staffing rating.
Interview on 03/05/25 at 8:10 A.M. with CNA #201 revealed call lights were often not answered timely due
to lack of staff, and staff often worked past their scheduled work hours in order to complete their job duties.
Interview on 03/05/25 at 8:57 A.M. with CNA #203 revealed the facility would send employees home if they
felt there were too many people working. She was often asked to stay over and pick up additional shifts to
help with staffing issues. She normally worked through her lunch break in order to complete all tasks, and
there were times she could not complete showers due to staffing issues.
Interview on 03/06/25 at 9:37 A.M. with CNA #201 revealed she was assigned 18 residents for the day, ten
of them required every two-hour check and change for incontinence. She was also responsible for getting
people out of bed and making sure residents were turned and repositioned every two hours. She revealed
the workload was often too much for one person to complete all tasks, and some tasks were left
uncompleted.
Interview on 03/06/25 at 9:59 A.M. with Scheduler #206 and the Administrator revealed the facility was
staffed based on census and acuity. The administrative team met daily and made changes to the schedule
as necessary, reaching out to employees who were not working and offering additional shifts. The
Administrator revealed she had no knowledge of concerns from staff, residents or families regarding
insufficient staff. She attributed the one-star rating for the PBJ to the use of agency staff at the time and
believed the rating had improved since the report had been submitted.
This deficiency represents noncompliance investigated under Master Complaint Number OH00162396 and
Complaint Number OH00161454.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366491
If continuation sheet
Page 9 of 9
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
FAQ · About this visit
Common questions about this visit
What happened during the March 6, 2025 survey of STRONGSVILLE HEALTHCARE AND REHABILITATION?
This was a inspection survey of STRONGSVILLE HEALTHCARE AND REHABILITATION on March 6, 2025. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at STRONGSVILLE HEALTHCARE AND REHABILITATION on March 6, 2025?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.