Health inspection·January 23, 2025

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of the facility's contract with therapy services, resident interview, and staff interview, the facility failed to administer the facility in a manner to maintain therapy equipment in proper working order. This affected one resident (#51) and had the potential to affect all 91 residents in the facility. Residents Affected - Many Findings include: Review of the medical record for Resident #51 revealed an admission date of 06/26/24 with diagnoses including encounter for other orthopedic aftercare, person injured in unspecified motor-vehicle, colostomy status and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/03/24, revealed Resident #51 had moderate cognitive impairment, was dependent on staff for bed/chair to chair transfers, and required partial/mod assist for bed mobility. On 01/22/25 at 7:48 A.M., an interview with Resident #51 stated the therapy gym did not have the equipment they needed and he was told by staff to just hold onto the sink and pivot while attempting to stand. On 01/22/25 at 8:33 A.M., an observation of the facility's therapy gym revealed there was an ultrasound and tens unit (electrotherapy device) on a shelf and there was a set of balance bars (parallel bars used to help people stay balanced while standing or walking) in the corner surrounded by walkers, rollators, canes, and other equipment, making the balance bars inaccessible to residents. On 01/22/25 at 8:36 A.M., an interview with Certified Occupational Therapy Assistant (COTA) #814 stated the facility did not have much therapy equipment and the ultrasound and tens unit were used for pain management but they had been unable to use them because the facility refused to pay for routine maintenance and calibration. COTA #814 also stated the balance bars could not be used because they were not secured to anything and unsafe in their current state. COTA #814 revealed they had to be super creative when providing therapy because they did not have the equipment they need. On 01/22/25 at 8:49 A.M., an interview with Rehabilitation Director #815 confirmed the ultrasound and tens unit had not been used since at least July 2024 because they needed serviced. She stated the therapy staff were contracted and the facility was responsible for maintaining therapy equipment. Rehabilitation Director #815 also confirmed therapy staff were unable to use the balance bars in the therapy gym because they were not secure and verified Resident #51 had to use a sink to support himself while standing up. Rehabilitation Director #815 revealed therapy gave the faciliy a list of Page 1 of 2 365129 365129 01/23/2025 Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112

F 0835 needs within the last month and has not received a response yet. Level of Harm - Minimal harm or potential for actual harm On 01/22/25 at 9:56 A.M., an interview with the Administrator verified the ultrasound and tens unit was due for maintenance in August 2024 and maintenance had not yet been completed. Administrator revealed they haven't had anyone with orders for the ultrasound and Tens unit since August 2024, indicating there was not hurry to get it serviced. Residents Affected - Many On 01/22/25 at 10:35 A.M., an interview with Occupational Therapist (OT) #816 stated they did need to use the ultrasound and tens unit for some residents (she was unable to specify who those residents were). On 01/23/25 at approximately 1:45 P.M., during the exit conference, the Administrator was adamant that although the therapy equipment was in the therapy gym at the facility, the facility was not required to keep the equipment in proper working order because it was not being used. The Administrator insisted the equipment was not used and did not need to be maintained, despite therapy staff stating they would use this equipment if it were in proper working order. Review of the facility's contract with therapy services, dated 07/01/24, revealed it was the facility's responsibility to provide, at its sole expense, all supplies and equipment necessary to provide services and the facility would keep such equipment in good order and repair. This deficiency represents non-compliance investigated under Complaint Number OH00161622 and OH00160645. 365129 Page 2 of 2