Inspection·August 21, 2024

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** Based on interview, record review, facility investigation review, and facility policy review the facility failed to ensure Resident #73 was transferred safely resulting in a fall. This affected one resident (#73) of three residents reviewed for accidents. Facility census was 83. Findings include: Review of Resident #73's medical record revealed an admission date of 05/10/19 with diagnoses included but not limited to systolic congestive heart failure, acute respiratory failure, acute kidney failure, and artificial opening of urinary tract status and need for assistance with personal care. Review of the care plan dated 05/10/19 revealed Resident #73 had an ADL self-care performance deficit related to activity intolerance and impaired balance. Interventions included toileting dependent with assist of two persons and mechanical lift with two person assist for transfers. Review of Resident #73's quarterly Minimum Data Set assessment dated [DATE] revealed the resident required substantial/maximal assistance with toileting hygiene and was dependent on staff for mobility. Review of the progress noted dated 06/14/24 at 4:49 P.M. authored by Licensed Practical Nurse (LPN) # 223 revealed she was notified by State Tested Nurse Aide (STNA) #305 regarding Resident #73 fell out of bed while being provided care with one assist for peri care. LPN #223 did an assessment, notifications, and started neurological (neuro) checks. LPN #223 and STNA #305 lifted resident back to bed with two-staff assistance without mechanical lift. Review of the investigation report dated 06/14/24 revealed Resident #73 received care by one staff and fell out of bed. LPN #223 assessed Resident #73, and she was lifted from floor mat back into bed with two staff assist manually. Resident #73 sustained no injuries or complaints of pain. Interview on 08/19/24 at 11:06 A.M. with Nurse Practitioner (NP) #326 revealed she was notified of the fall and reported the STNA #305 was new and was only using one assist for care and there should have been two assisting with peri care/toileting. Interview on 08/19/24 at 11:53 A.M. with LPN #223 revealed STNA #305 reported Resident #73 had fallen out of bed during peri care/toileting. LPN #223 reported she believed Resident #73 was a two person assist for peri care/toileting. (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 3 Event ID: 365129 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 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 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)