Gardens Of Euclid Beach

Review of the facility policy, Shower/Tub Bath, dated 10/2010, revealed the purpose of this procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.

The following information should be recorded on the resident's Activity of Daily Living (ADL) record and/or in the resident's medical record: date and time the shower/tub was performed, name and title of the individual who assisted the resident with the shower/tub bath, all assessment data obtained during the shower/tub bath, how the resident tolerated the shower/tub bath, if the resident refused, what intervention was taken and the signature with title of the person recording the data.

This deficiency represents noncompliance investigated under Complaint Number 1381901.

365594 09/23/2025

Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110

responsible for coordinating the rescue effort and directing other team members during the rescue

jeopardy to resident health or individual was found unresponsive, briefly assess for abnormal or absence of breathing. If sudden safety cardiac arrest was likely, begin CPR.

Instruct a staff member to activate the emergency response system (EMS) and call 911.

Instruct a staff member to retrieve the automatic external defibrillator

facility policy Charting and Documentation last revised [DATE] revealed documentation of procedures and treatments would include care-specific details, including: the date and time the procedure/treatment was provided; the name and title of the individual(s) who provided the care; the assessment data and/or any unusual findings obtained during the procedure/treatment; how the resident tolerated the procedure/treatment; whether the resident refused the procedure/treatment; notification of family, physician, or other staff, if indicated; and the signature and title of the individual documenting.

This deficiency represents noncompliance investigated under Master Complaint Number 2612264 and Complaint Numbers 2578214 and 1381901.

365594 09/23/2025

Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110

During the interview LPN #532 revealed she remembered when Resident #58 coded. LPN #532 said the resident was in respiratory distress and RN #511 gave her an inhaler, then an aerosol treatment, then had to retrieve oxygen the resident wanted from the second floor. LPN #532 said the next thing she knew RN #511 returned to the second floor calling for help. LPN #532 said she and an unidentified aide went back to the first floor with RN #511.

RN #511 and LPN #532 grabbed the crash cart and went to the resident's room while the aide called

• LPN #532 said she thought Resident #58 had a pulse still as the pulse oximeter was picking up

an oxygenation level.

She stated RN #511 did not check for a pulse before starting CPR. LPN #532 said CPR continued until EMS arrived and took over.

They transported Resident #58 to the ER where she was pronounced expired.

Interview with DoR #565 on [DATE] at 10:50 A.M. revealed he had worked with Resident #58 on [DATE] and denied the resident had any concerns, complaints of shortness of breath, not feeling well, or chest pain.

The DoR revealed the resident presented as per her normal and there was nothing out of the ordinary with the resident.

The DoR revealed he was surprised when he heard the next day the resident had passed away.

Interview with LPN #510 on [DATE] at 11:15 A.M. revealed she recalled Resident #58.

The LPN revealed the resident was on the first floor in the new unit that opened sometime in [DATE]. LPN #510 said the resident was alert, independently mobile, and knew what she wanted. Resident #58 never complained about being short of breath, not feeling well, or chest pain.

Interview with MD #614 on [DATE] at 11:35 A.M. revealed he was the only physician for the [TRUNCATED]

365594 09/23/2025

Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110

1381901 and Complaint Number 1381896.

365594 09/23/2025

Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110

Review of the facility policy called Smoking Policy-Residents Acknowledgement, revised December 2016, revealed prior to and upon admission, residents shall be informed of the facility smoking policy, and designated smoking areas.

Smoking is only permitted in the designated resident smoking area which is located outside of the building.

Smoking is only permitted during designated times for residents that require supervision.

Upon admission the resident will be evaluated to determine if he or she is a smoker or non-smoker and ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation).

Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member at all times while smoking.

Residents with restricted smoking privileges are not permitted to keep cigarettes, pipes or other smoking articles in their possession.

This deficiency represents noncompliance investigated under Complaint Numbers 2578214 and 1381901.

365594 09/23/2025

Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110

Review of the Facility Assessment, dated [DATE], revealed staff training, staff education and competencies training program includes an orientation process and ongoing training for all new and existing including managers, nursing, and other direct care staff, individuals providing services under contractual arrangement, and volunteers consistent with their expected roles.

The facility completes an emotional need assessment and develop a curriculum and training plan based on staff need and resident characteristics.

The content at a minimum includes effective communication; resident rights and facility responsibilities; abuse, neglect, and exploitation; infection control; culture change/person-centered care; dementia management and abuse prevention; special needs of residents; caring for residents who are cognitively impaired; identification of resident changes in condition; cultural competency/trauma informed care; QAPI (Quality Assurance and Performance Improvement); compliance and ethics; emergency preparedness; and workplace hazards.

The facility conducts a formal evaluation of the training program.

The purpose statement noted the purpose statement of this assessment is to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Facility resources included all personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care.

This deficiency represents noncompliance investigated under Complaint Number 1381901.

365594 09/23/2025

Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110

Observation on 08/20/25 at 3:21 P.M. of the crystal [NAME] hall medication cart revealed there were 20 loose pills of various shapes and colors in the bottom of the medication cart.

Interview on 08/20/25 at 3:21 P.M. with LPN #607 confirmed 20 loose pills of various shapes and colors in the bottom the nurse of the crystal [NAME] hall medication cart. LPN #607 confirmed she was not able to identify the 20 pills nor to whom the 20 pills were prescribed.

Observation on 08/20/25 at 3:47 P.M. of the carousel hall revealed there were 5 loose pills of various shapes and colors in the bottom of the medication cart.

Interview on 08/20/25 at 3:47 P.M. with LPN #578 confirmed five loose pills of various shapes and colors in the bottom of the medication cart for the carousel hall cart confirmed she was not able to identify the five pills nor to whom the five pills were prescribed.

Review of the facility policy titled, Storage of Medications, dated 04/07, revealed drugs and biologicals should be stored in the packaging in which they are received and the nursing staff is responsible for maintaining medication storage.

This deficiency represents non-compliance investigated under Complaint Number

• 365594 09/23/2025

Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110

Review of the physician order dated 11/21/23 for Resident #53 revealed an order for a BMP (Basic Metabolic Panel) and CBC (Complete Blood Count) to be completed every three months with no further directions specified.

Review of the medical record for Resident #53 revealed no evidence of a BMP or CBC being completed on 07/15/25 as ordered.

Review of the care plan last reviewed on 07/23/25 for Resident #53 revealed resident at risk for adverse effects related to use of psychoactive medications and diagnosis of depression. Resident #53 also had a diagnosis of depression related to pain management needs.

Intervention for both listed included obtain lab results as ordered and notify the physician of abnormal values.

Review of the 08/15/25 annual Minimum Data Set (MDS) 3.0 assessment for Resident #53 revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15 which indicated moderate cognitive impairment. Resident #53 was also noted to have a diagnosis of depression and received antidepressant, antiplatelet and anticonvulsant medications.

Interview on 08/25/25 at 3:14 P.M. with Regional Director of Clinical [NAME] (RDCS) #601 confirmed the BMP and CBC was last completed on 04/15/25 but was unable to provide evidence that the BMP and CBC were completed as physician ordered on 07/2025.

Interview on 09/03/25 at 2:47 P.M. with RDCS #601and Regional Director of Operations (RDO) #599 confirmed they were unable to provide a facility policy related to physician orders being followed.

This deficiency represents noncompliance investigated under Complaint Number 1381901.

365594 09/23/2025

Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110

Review of the medical record for Resident #4 revealed an admission date of 03/20/25.

Diagnoses included multiple sclerosis, morbid obesity and type two diabetes mellitus.

Review of the 07/01/25 quarterly MDS 3.0 assessment for Resident #4 revealed intact cognition. Resident #4 was noted to receive a regular diet, required set-up for meals and was dependent upon staff for ADL.

An observation on 08/21/25 at 1:54 P.M. with RDM #598 of Resident #4's room refrigerator revealed no temperature monitoring log on or around the refrigerator. A 12.05-ounce (oz) plastic container of pre-prepared beef stew was found and had an expiration date of 07/03/25, an eight-ounce container of parmesan cheese was found with an expiration date of 08/19/23.

Interview with RDM #598 at the time of the observation verified the findings.

An interview on 08/28/25 at 10:08 A.M. with Resident #4 revealed she was unsure if anyone ever checked her refrigerator or monitored temperatures and stated if they had then it was not being done consistently.

Review of the facility policy titled Food Brought in for Patients and Residents, dated 11/27/17, revealed food brought to residents by family or visitors will be handled and stored in a safe and sanitary manner and may be stored in personal refrigerators in resident rooms.

Food items that require refrigeration must be labeled, dated and will be held in the refrigerator for three days after the date on the label then discarded by staff.

Foods considered unsafe or beyond the expiration date will be discarded by staff.

The policy did not specify any procedure or instructions related to maintaining and monitoring safe food temperatures in resident room refrigerators.

This deficiency represents non-compliance investigated under Complaint Number 2578214.

365594 09/23/2025

Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110

The facility failed to ensure a clean and sanitary

affect all residents residing in the facility.C.

The facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call emergency medical services (EMS) for Resident #13 resulting in immediate jeopardy and death. D.

The facility failed to ensure showers/bathing was completed and documented as required for twelve residents (Residents #1 #2, #3, #5, #7, #29, #41, #44, #45, #53, and #63) of 44 residents who required staff assistance for showers and bathing.E.

The facility failed to ensure physician ordered labs were completed timely for Resident #53.F.

The facility failed to ensure medical record documentation included weekly skin assessments as ordered and care planned for 11 residents (#1, #3, #7, #9, #29, #44, #45, #49, #53, #63, and #69) and failed to ensure the change of condition and subsequent death of Resident #76 was documented in the medical record.

This affected 12 residents (#1, #3, #7, #9, #29, #44, #45, #49, #53, #63, #69 and #76) of 22 residents reviewed for complete resident records.G.

The facility failed to have an updated and accurate facility assessment to indicate sufficient staffing for the first floor.

This had the potential to affect six residents identified as residing on the first floor (Residents #22, #26, #31, #35, #46 and #61).H.

The facility failed to ensure Resident #29 was provided corrective lens and vision care appointments per physician orders.I.

The facility failed to ensure a complete orientation of new certified nurse assistants and licensed nurses.

This had the potential to affect all residents residing in the facility.J.

The facility failed to ensure sufficient competent staffing on the first floor which had the potential to affect six residents (#22, #26, #31, #35, #46 and #61) who resided on the first floor of the facility.K.

The facility failed to ensure quality assurance team consisted of the required members.

This had the potential to affect all residents living in the facility.L.

The facility failed to ensure resident personal refrigerators were monitored for temperatures and food spoilage.M.

The facility failed to ensure appropriate supervision during smoking times and failed to ensure residents did not have smoking items in their personal possession which affected Resident #45 and #49.N.

The facility failed to ensure oxygen tubing was dated when changed for Resident #39 and #55.O.

The facility failed to ensure pharmacy reviews were completed monthly for Resident #4 and #53.P.

The facility failed to ensure the physician was notified of changes in condition for Resident #13 and #85.Q.

The facility failed to ensure a catheter drainage bag was covered for Resident #27.R.

The facility failed to ensure medications were properly secured.S.

The facility failed to ensure appropriate quality of care for three residents (Resident #13, #58, and #74) resulting in immediate jeopardy and death.

This deficiency represents non-compliance investigated under Complaint Numbers 2578214 and 1381901.

365594 09/23/2025

Gardens of Euclid Beach 16101 Euclid Beach Blvd Cleveland, OH 44110

and the closet.

The wall was exposed with a hole in it.

The privacy curtain was not hung correctly.

were not hung correctly.

There was rust noted around the sink.

Built up dirt and debris was noted

heating unit. room [ROOM NUMBER] was noted to have a privacy curtain that was not hung correctly.

There was wall damage noted to the left of the entry door in the hall between the lower rail and baseboard. room [ROOM NUMBER] was noted to have wall damage to the lower wall between the television stand and the bathroom. room [ROOM NUMBER] was noted to have a heating unit without a cover on it.

There was wall damage between the television stand and the bathroom. room [ROOM NUMBER] was noted to have peeling wallpaper.

There was visible dirt and debris behind the door. room [ROOM NUMBER] was noted to have peeling wallpaper. room [ROOM NUMBER] was noted to have window curtains not hung correctly.

There was peeling wallpaper on the lower right hand corner of the wall between the bathroom and the door. room [ROOM NUMBER] was noted to have build up visible dirt behind the door.

There was built up visible dirt on top of the heating unit.

The back left wall of the bathroom was noted to have no wallpaper and wall damage.The aforementioned was verified by Housekeeping and Laundry Supervisor #550 at the time of the observations.On 08/27/25 at 10:40 A.M. an interview with Housekeeper #575 revealed the department was short-staffed and deep cleaning of resident rooms had not been done.A review of the documents titled; Room Rounds dated 07/01/25, 07/02/25, 07/03/25, 07/07/25, and 07/14/25 revealed multiple issues with wallpaper and housekeeping. On 08/19/25 at 11:30 A.M. RDO #599 verified the dates for July 1st, 2nd, 3rd, 7th and 14th and no further room checks after 07/14/25. RDO #599 was unable to say how often room rounds were conducted as she was new to the position.A review of the document titled; Gardens of Euclid Beach TELS Mock survey dated 04/08/25 revealed The overall appearance of the facility including condition of the roof and obstructed doorways was a work in progress.

Renovation was noted to be in progress.

Landscaping beds were not welcoming and not kept up. A fence in the front of the building was noted to be not in good repair.

There was trash noted along the back of the building.A review of an email dated 07/17/25 to VPO #605 and Licensed Nursing Home Administrator #627 revealed there was a bulk of cosmetic stuff in the building that can be fixed with mud and paint.

The email further revealed the TELS system (a system for logging needed building repairs) should be addressed daily.A review of an untitled document that was identified as the deep cleaning schedule by RDO #599 revealed rooms are to be deep cleaned weekly.

There was no cleaning schedule noted for deep cleaning for the units on the first floor.A review of the document titled; daily room cleaning checklist that was undated revealed The toilet seat is to be clean and sanitized and the outer bowl of the toilet is to be cleaned down to the floor.

The underside of the toilet seat and inner bowl of the toilet is to be cleaned.

The room is to be spot swept for large trash and food items.

Sweep behind and under beds and furniture as well as possible.

The room and bathroom is to be mopped in its entirety starting from the window wall and working to the entry door.A review of the policy titled; Quality of Life-Homelike Environment dated 05/2017 Revealed residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use personal belongings to the extent possible.

The facility staff and management shall maximize to the extent possible the characteristics of the facility that reflect A personalized, home like setting.

These characteristics include a clean sanitary and orderly environment.This deficiency represents non-compliance investigated under Complaint Numbers 2578215, 2578214, 1381903, 1381901, and 1381896.