North Royalton Post Acute

Inspectors wroteBased on closed record review, hospital record review, review of facility fall investigations, facility policy review and interview, the facility failed to develop and implement a comprehensive, individualized and effective fall/safety plan of care to prevent repeated falls including falls with injury for Resident #97. This affected one resident (#97) of three residents reviewed for falls. The facility census was 96. Actual Harm occurred on 12/23/25 when Resident #97, who was at high risk for falls (with four falls between 12/17/25 and 12/22/25) and who had behaviors (agitation/restlessness) sustained a fall from bed resulting in a hematoma and visible injury to her right temple without evidence of comprehensive, individualized and effective interventions being in place to prevent the fall. [...]

Inspectors wroteBased on resident record review, staff interviews, and facility policy review, the facility failed to provide a timely response to resident concerns. This affected one resident (#33) of three reviewed for resident's rights. The facility census was 96.

Inspectors wroteBased on record review, interview, observation, and facility policy review, the facility failed to ensure urinary catheter care was provided according to professional standards of practice, and failed to ensure urinary catheter and colostomy care were provided and in a timely manner to Resident #49. This affected one resident (#49) of three residents reviewed for bowel and bladder care. The facility census was 96.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure Resident #33 was free from significant medications errors. This affected one Resident (#33) of three reviewed for medication administration. The facility census was 96.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to properly disinfect glucometers after resident use. This affected one Resident (#33) of three residents reviewed for infection control and had the potential to affect six additional residents (#2, #20, #33, #51, #61, and #90) on the nurse's assignment that received blood glucose checks. The facility census was 96.

Inspectors wroteBased on observation, interview and record review, the facility failed to timely assist Resident #91 to get out of bed per his request and failed to provide foot pedals per request for Resident #83. This affected two residents (Resident #91 and #83) of three residents observed for timely accommodation of needs/requests. The facility census was 119.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to notify the physician timely and monitor the resident for adverse effects after a medication error occurred. This affected one resident (Resident #44) of three residents reviewed for medication errors. The facility census was 119.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #14 received timely assistance to maintain continence. This affected one resident (Resident #14) of three residents observed for incontinence care. The facility census was 119.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure #78 received the ordered amount of tube feeding daily. This affected one resident (Resident #78) of three residents reviewed for tube feeding management. The facility census was 119.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5%. A total of 31 medications were administered with two errors for a medication error rate of 6.45%. This affected two residents (Resident #26 and Resident #79) of five residents observed for medication administration. 1. Record review for Resident #26 revealed an admission date of 02/09/23. Diagnosis included Type one diabetes mellitus (DM) with diabetic neuropathy and hypertensive chronic kidney disease with stage one through stage four chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact. Resident #26 had DM and required insulin injections. [...]

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to maintain infection control practices for one Resident #91 during incontinence care and wound care. This affected one resident (Resident #91) of three residents observed for infection control. The facility census was 119.

Inspectors wroteBased on interview and record review the facility failed to ensure a comprehensive discharge care plan was in place for Resident #99. This affected one resident (Resident #99) out of three residents reviewed for comprehensive care plans. The facility census was 95.

Inspectors wroteBased on interview, closed medical record review, and facility policy review, the facility failed to ensure Resident #71, Resident #93, Resident #99 skin impairments were thoroughly assessed, monitored and treated timely. This affected three residents (#71, #93, and #99) out of three residents reviewed for skin impairments. The facility census was 95.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interview the facility failed to ensure the facility assessment was updated and accurate. This had the potential to affect all residents. The facility census was 83.

Inspectors wroteBased on observations, review of facility policy and procedures, interviews with the Communicable Disease Investigator and facility staff and review of the Centers for Disease Control and Prevention guidelines, the facility failed to implement effective infection control practices including a system to ensure the availability and appropriate use of personal protective equipment (PPE) by staff, a system to ensure staff were donning and doffing PPE when required. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure Resident #52 received frequent mouth care. This affected one (Resident #52) of three residents reviewed for activities of daily living. The facility census was 81 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure peripherally-inserted central catheter (PICC) protective dressings were changed weekly according to facility policy and standards of practice. This affected one (Resident #71) of one resident reviewed for proper intravenous access (IV) care. The facility census was 81 residents.

Inspectors wroteBased on observation interview, record review, and policy review the facility failed to ensure proper infection control measures were followed during incontinence care and wound care. This affected two (Residents #12 and #71) of three residents reviewed for infection control. The facility census was 81 residents.

Inspectors wroteBased on observations, staff interviews, review of the medical record, police report, emergency room documentation, accuweather.com, timeanddate.com, and the facility's Wandering And Exit Seeking policy and procedure, the facility failed to provide adequate supervision to prevent the elopement of one resident (Resident #204) who was assessed with severe cognitive impairment and exit seeking behaviors. This resulted in Immediate Jeopardy on 05/09/19 at approximately 5:45 A.M. when Resident #204 exited the facility without staff knowledge. The likelihood of actual harm that was Immediate Jeopardy occurred when Resident #204 was found on his knees in his bare feet at the bottom of a ravine with an incline of approximately 70 degrees next to a creek. The ravine contained heavy brush, weeds, downed trees, rocks, and large tree branches. [...]

Inspectors wroteBased on observation and interview the facility failed to maintain sanitary conditions in the kitchen. This had the potential to affect all residents except seven residents, #43, #258, #99, #70, #54, #97, and #93, who received nothing by mouth.

Inspectors wroteBased on record review and resident interview the facility failed to ensure it had evening weekend activities in-place to engage the residents. This affected Residents #5 #9, #18, #22 and #27. The facility census was 111. Findings Include: During the resident council meeting on 05/08/19 between 1:30 P.M. and 1:50 P.M., Residents #5 #9,#18, #22 and #27 voiced concerns related to the lack of evening activities on the weekends. Resident #18 notably described the facility as dull on weekend evenings. Review of the resident council meeting minutes revealed concerns regarding lack of evening activities were brought to the facility's attention in October 2018. Review of the activity calendar for the current month noted three identical activities and times on each Sunday and Saturday. The last activity was scheduled at 2:00 P.M. [...]

Inspectors wroteBased on record review and staff interview the facility failed to follow code status orders for Resident #57. This affected one of two residents whose closed records were reviewed.

Inspectors wroteBased on record review and staff interview the facility failed to ensure monthly physician orders were signed and dated as required. This affected three (Residents #10, #24 and #89) of twenty six residents reviewed. The facility census was 111. Findings Include: Review of the medical records for Residents #10, #24 and #89 on 05/07/19 between 1:00 P.M. and 2:00 P.M. revealed the following: 1. The monthly physician orders for Resident #10 for April 2019, March 2019, February 2019, January 2019, December 2019, November 2018 and October 2018 were not signed by the resident's physician (Physician #975). 2. The monthly physician orders for Resident #24 for April 2019, March 2019, February 2019 and January 2019 were not signed by the resident's physician (Physician #975). 3. [...]