Inspection visit
Health inspection
23 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 23 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
365594
10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0553
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interviews, the facility failed to ensure Resident #107 had care plan meetings as required. This affected one (Resident #107) of two residents reviewed for care plan meetings. The facility census was 112.
Findings include: Review of the medical record for Resident #107 revealed he was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, hypertension, chronic viral hepatitis C, retention of urine and prostate cancer. Resident #107 was interviewed on 10/06/19 at 11:32 A.M. and stated he had not been invited to or participated in any care plan meetings since he was admitted . Further review of the medical record for Resident #107 revealed no documentation that any care plan meetings had been held. Social Worker (SW) #89 was interviewed on 10/08/19 at 10:00 A.M. and stated resident care conferences were held quarterly. SW #89 verified on 10/08/19 at 10:59 A.M. that no care conferences had been held with Resident #107 since his admission on [DATE].
Page 1 of 30
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365594
10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0577
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Level of Harm - Potential for minimal harm
Based on record review and staff interview, the facility failed to have three years of state survey results, including complaint investigations, readily accessible to residents and the general public. This had the potential to affect all 112 residents.
Residents Affected - Many
Findings include: Review of the facility's public survey results book on 10/06/19 at 1:20 P.M. revealed a complaint survey dated 02/15/18 was the last survey included in the book. The Ohio Department of Health conducted surveys at the facility on 04/24/18, 07/12/18, 08/07/18 (violations issued), 10/04/18 (violations issued), 11/20/18, 12/03/18 (violations issued), 01/09/19, 03/25/19, 05/14/19 (violations issued), 06/11/19, 07/15/18, 08/05/19 and 09/05/19. The results of these surveys were not included in the survey book at the time of observation. On 10/06/19 at 3:05 P.M., the Administrator verified the survey results for the surveys listed above were not present in the book and readily available for review.
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Page 2 of 30
365594
10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0578
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure accurate advanced directive information was present throughout the medical record for Resident #12. This affected one of one resident (Resident #12) reviewed for advanced directives. The facility census was 112.
Findings include: Review of the medical record for Resident #12 revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, Alper's disease (a progressive neurological disorder), paranoid schizophrenia and psychosis. Review of the physician's orders for October 2019 revealed Resident #12 was a full code. Further review of the medical record for Resident #12 revealed a red sheet of paper under the advanced directive tab with do not resuscitate comfort care (DNRCC) printed on it. Registered Nurse (RN) #158 was interviewed on 10/09/19 at 11:24 A.M. and verified Resident #12's code status was DNRCC, and the physician's order for full code was incorrect.
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Page 3 of 30
365594
10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm or potential for actual harm
Based on record review and staff interview, the facility failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) form was given to Resident #73 upon the discontinuation of skilled services. This affected one (Resident #73) of three residents reviewed for proper notices of non-coverage. The facility census was 112.
Residents Affected - Few
Findings Include: Review of the medical record for Resident #73 revealed Resident #73 was given a Notice of Medicare Non-Coverage (NOMNC) on 09/26/18 indicating skilled services was would be discontinued on 09/28/19. Review of census records revealed Resident #73 remained in the facility. Further review of the medical record revealed Resident #73 did not receive a SNF ABN as required. Interview with Social Worker #89 on 10/08/19 at 10:55 A.M. verified the lack of notice. He stated he was unaware that a SNF ABN form needed to be issued when residents remained in the facility and were discontinued from Medicare services.
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Page 4 of 30
365594
10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm or potential for actual harm
Based on staff interview, review of personnel files and the abuse policy and procedure, the facility failed to develop and implement policies and procedures to include screening of all employees against the State of Ohio Nurse Aide Registry to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property and failed to obtain reference checks. This affected six employee files (Licensed Practical Nurse (LPN) #103, LPN #301, Director of Admissions #54, Housekeeping Assistant #82, Human Resource Director (HRD) #100 and the Administrator) of eleven personnel files reviewed for screening against the State of Ohio Nurse Aide Registry and four employee files (LPN #301, State Tested Nurse Aide (STNA) #35, STNA #151 and Floor Technician #83) of eleven personnel files reviewed for reference checks. This had the potential to affect all 112 residents residing in the facility resulting in substandard quality care.
Residents Affected - Many
Findings include: Review of eleven personnel files revealed six staff were not checked against the State of Ohio Nurse Aide Registry. LPN #103, LPN #301, Director of Admissions #54 and Housekeeping Assistant #82 had no evidence they were screened using the State of Ohio Nurse Aide Registry. HRD #100 and the Administrator were not checked against the Nurse Aide Registry until 10/09/19. STNA #36, #83, #131, #151 and #166 had evidence they were screened on the State of Ohio Nurse Aide Registry and were in good standing. The identification of findings would be necessary to determine if any employee had actions identified that would validate allegations of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property. Interview with HRD #100 on 10/09/19 at 5:20 P.M. stated she was not aware employees other than STNA's had to be checked against the State of Ohio Nurse Aide Registry for negative findings. She verified she had not being checking all new hires. HRD #100 provided a list indicating there were 179 staff hired since the last annual survey of 10/11/18. There were 91 staff identified as STNA's, and the remaining 88 staff should have been checked against the State of Ohio Nurse Aide Registry. Review of LPN #301, STNA's #35 and #151 and Floor Technician #83's personnel files lacked evidence their references had been checked prior to employment. Interview with HRD #100 on 10/09/19 at 4:30 P.M. verified references were not obtained on the four staff listed above. HRD #100 provided dates of service on a reference check form for two staff she had them fill out themselves. Review of the abuse prevention policy and procedure, revised November 2017, lacked indication that checking all staff against the State Nurse Aide Registry was part of screening. Review of the abuse policy and procedure, revised December 2016, indicated as part of the resident abuse prevention, the administrator will conduct employee background checks and will not knowingly employ or otherwise engage any individual who have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property.
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Page 5 of 30
365594
10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the comprehensive assessment was coded correctly for Resident #48 for vision, Resident #34 for medications, Resident #115 for discharge location, Resident #12 for refusal of care and Resident #5 for life expectancy. This effected five of 35 Residents (#5, #8, #12, #14, #16, #23, #26, #27, #34, #37, #43, #48, #51, #57, #58, #61, #64, #66, #75, #78, #79, #82, #92, #97, #99, #103, #104, #107, #108, #109, #111, #113, #115, #163 and #313) reviewed for assessment accuracy. The facility census was 112.
Residents Affected - Some
Findings include: 1. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including psychosis, symbolic dysfunction, abnormality of gait, altered mental status, insomnia and dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the residents vision was adequate, and she had no corrective lens. Interview on 10/06/19 at 9:38 A.M. with the residents responsible party revealed the resident was admitted with glasses, but they have disappeared and she was unsure if the resident had been seen for vision consult. Review of the resident record revealed the resident was seen for a vision exam on 11/07/18 and had a prescription for glasses. Interview on 10/08/19 at 10:18 A.M with Licensed Practical Nurse (LPN) #107, she stated she had never seen the resident wear glasses. She stated she was not aware if the resident had glasses in her room. LPN #107 had been employed with the facility since 07/21/17 and had worked with the resident frequently. Interview on 10/08/19 at 11:04 A.M. with Licensed Social Worker (LSW) #89, the surveyor asked if the resident received glasses as a result of her 11/07/18 eye appointment, and if she didn't, why not. He stated he would have to check his notes. He stated he had documentation that the resident had received new glasses in 10/2016. When surveyor asked where the glasses were, he indicated he would search the residents room. On 10/08/19 at 2:38 P.M. LSW #89 reported he could not find the glasses. Interview on 10/08/19 at 2:38 P.M. with LPN#16 revealed the resident was capable of seeing fine and wandered around the facility without incident. She indicated the coding for vision was correct. Interview on 10/09/19 at 7:50 A.M. with State Tested Nursing Assistant (STNA) #134 indicated she had never seen the resident with glasses. STNA #134 had been employed with the facility since 06/06/19 and frequently worked with the resident. Observation and interview with Resident #48 on 10/09/19 at 9:40 A.M., the resident was in the activity room staring at the dry erase board that had the activity calendar on it, which was newspaper size print. The surveyor pointed to the word End and asked the resident if she knew what that word was. The resident lowered her face to approximately three inches from the board then looked at surveyor and giggled. The surveyor again asked the resident what the word was. The resident again lowered her face to the board to within three inches to see the word and again giggled then hugged the surveyor. The surveyor pointed to a group of three pumpkins on the bottom right of the calendar and asked
365594
Page 6 of 30
365594
10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0641
Level of Harm - Minimal harm or potential for actual harm
the resident if she knew what they were. Again the resident lowered her face to within three inches of the calendar, then turned to look at the surveyor and smiled. The resident was not interviewable, however she consistently lowered her face towards the calendar to see the word and picture the surveyor was pointing to.
Residents Affected - Some The coding of Adequate was incorrect. 5. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Her admitting diagnoses included malignant neoplasm of the prostate, hypertension, Alzheimer's disease and chronic kidney disease. Resident #5's MDS 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment. She required extensive assistance for all activities of daily living including eating, personal hygiene and toilet use. The resident had been on hospice since April, 2019. Further review of the MDS dated [DATE] revealed under section J1400, which asks if this resident has a condition or chronic disease that may result in a life expectancy of less than 6 month, the facility answered no. Interview with MDS Nurse, LPN #15, on 10/07/19 at 11:50 A.M. revealed this section was coded incorrectly, and the question should have been answered with a yes since the resident was a hospice resident. 2. Review of the medical record for Resident #12 revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, Alper's disease (a progressive neurological disorder), paranoid schizophrenia and psychosis. Review of the significant change MDS 3.0 assessment for Resident #12 dated 07/02/19 revealed Resident #12 had not rejected care during the assessment reference period. Review of the care plan for Resident #12 revealed she was noncompliant with care and would refuse care and medications. Review of the Medication Administration Record for June 2019 revealed Resident #12 had refused medications on 06/26/19, 06/27/19, 06/28/19, 06/29/19 and 06/30/19. LSW #89 was interviewed on 10/09/19 at 11:02 A.M. and verified the MDS assessment was coded inaccurately. 3. Review of the medical record for Resident #34 revealed he was admitted to the facility on [DATE] with diagnoses including end stage renal disease, diabetes mellitus, hypertension, glaucoma and amputation of the left lower leg. Review of the quarterly MDS 3.0 assessment for Resident #34 dated 07/05/19 revealed he had been coded as receiving antipsychotic medications seven days, anticoagulants (blood thinners) seven days, and diuretics (water pills) seven days during the assessment reference period. Review of Resident #34's physician's orders for June 2019 and July 2019 revealed no orders for
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365594
10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0641
antipsychotics, diuretics, or anticoagulants.
Level of Harm - Minimal harm or potential for actual harm
Review of Resident #34's MARs for June 2019 and July 2019 revealed no antipsychotics, diuretics, or anticoagulants were administered to Resident #34.
Residents Affected - Some
Registered Nurse (RN) #18 was interviewed on 10/09/19 at 11:03 A.M. and verified the MDS assessment was coded inaccurately. 4. Review of the closed medical record for Resident #115 revealed he was admitted to the facility on [DATE] and discharged on 07/15/19. Review of the discharge MDS 3.0 assessment for Resident #115 dated 07/15/19 revealed Resident #115 had been discharged to the hospital. Review of the medical record for Resident #115 revealed a physician order dated 07/12/19 stating Resident #115 was to be discharged home. Further review of the medical record for Resident #115 revealed home discharge instruction, dated 07/15/19. RN #18 was interviewed on 10/08/19 at 10:00 A.M. and verified Resident #115 was discharged home, and the MDS assessment was coded inaccurately.
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Page 8 of 30
365594
10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0656
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and physician notes, the facility failed to ensure a care plan was initiated for a resident admitted with a chronic cough. This affected one resident (Resident #64) of 35 residents whose care plans were reviewed. The facility census was 112.
Findings include: Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. Her admitting diagnoses included respiratory failure with hypoxia, major depressive disorder, anxiety disorder, cerebral infarction, tracheostomy and type II diabetes. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. She required extensive assistance of two staff for most activities of daily living including transfers, toilet use and personal hygiene. Review of the nurse practitioner notes dated 09/10/19 indicated the resident was evaluated for a low grade temperature of 99.1 degrees Fahrenheit (F). The note stated the resident was having a frequent most cough. Per this note, the nurse practitioner stated the resident has had a chronic moist cough. Review of the care plans initiated for this resident from her admission to present showed no care plan for care of her chronic cough. Interview with Resident #64 on 10/08/19 at 9:10 A.M. revealed the resident has had a chronic cough since she had her tracheostomy placed. She stated that the cough just seemed to happen more often since her tracheostomy was removed. She stated it was the worst at night and sometimes kept her awake. When asked if she received medicine for her cough, she stated she did not think so. Interview with Regional Nurse #158 on 10/09/19 at 11:30 A.M. revealed the resident did have a care plan for alteration in breathing but this care plan did not address her chronic cough. She verified there was no care plan initiated for this resident's chronic cough.
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Page 9 of 30
365594
10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0657
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents care plans were updated to meet the residents needs. This affected one resident (Resident #43) of 35 residents whose care plans were reviewed.
Findings include: Review of the medical record revealed Resident #43 was admitted to the facility on [DATE]. His admitting diagnoses included epilepsy, heart failure, hypertension, atrial fibrillation, dementia and Clostridium Difficile (C. Diff), a highly contagious bacteria, in the stool. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment. She required extensive assistance for most activities of daily living, including toileting. She was totally dependent on staff for transfers and eating. Review of the physician's orders revealed on 09/24/19 she was diagnosed with C. Diff in her stool, and she was placed on isolation precautions. Review of the resident's plan of care dated 09/30/19 indicated Resident #43 was on contact isolation precautions related to C. Diff in her stool. Interventions included: All staff were to use personal protective equipment (PPE) when providing care to the resident; Dispose of soiled linens or clothing per contact isolation guidelines in dedicated waste and laundry receptacles; and use alcohol based cleaners when cleaning resident's tables, bed rails, sinks and toilet etc. Per the guidelines of cleaning of rooms of resident's with C-diff, alcohol based cleaners and alcohol based hand sanitizers do not kill the spores of C. Diff. Interview with Regional Nurse #158 on 10/08/19 at 9:40 A.M. revealed the intervention of the use of alcohol based cleaners for the resident's room was not updated/changed to the use of bleach cleaner.
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Page 10 of 30
365594
10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0660
Plan the resident's discharge to meet the resident's goals and needs.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a safe and accurate discharge for Resident #313 . This affected one resident (Resident #313) of two residents reviewed for the discharge process.
Residents Affected - Few
Findings include: Review of the medical record of Resident #313 revealed an admission date of 06/17/19. Her admitting diagnoses included type II diabetes, pneumonia, heart failure, hypothyroidism and atrial fibrillation. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed this resident was alert and oriented. She required supervision of one staff for most activities of daily living, including personal hygiene and toileting. Interview with the Director of Nursing (DON) on 10/06/19 at 9:30 A.M. revealed that residents, depending on their insurance, can be discharged with their medications from the medication cart. She stated the discharging nurse will reconcile the discharge medications against the resident's medication card to make sure the resident is getting the correct medication. The DON stated that Resident #313's sister came to the facility a couple days after discharge because the resident was given, along with her own medication, the medication of two other residents, Resident #82 and Resident #26. The DON also stated that when she realized what had happened, she initiated a concern form and did an investigation. The DON also stated at this time that she asked the sister if the resident was ok since according to the sister she was taking the medication. The sister stated the resident was fine. Further review of this resident's closed record on 10/06/19 at 11:00 A.M. revealed the resident was discharged with a medication card of Omeprazole (medication to treat gastroesophageal reflux disease) 20 milligrams (mg) to be taken daily belonging to Resident #82 and another card of Omeprazole 20 mg to be taken daily belonging to Resident #26. Interview with Licensed Practical Nurse (LPN) #301 on 10/06/19 at 12:12 P.M. revealed she was the nurse who actually discharged the resident. When asked about how she gave the resident her medications to take home, she stated she took the cards out of her slot in the medication cart and then she compared them with the discharge medication list. When asked how the resident still got the medication cards of two other residents when she did the medication reconciliation, she stated she did not know. Interview with the DON on 10/06/19 at 1:15 P.M. verified the resident was discharged with the medication cards of two other residents. This deficiency substantiates complaint number OH00107332.
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Page 11 of 30
365594
10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0676
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure there was intervention for prevention of functional decline in abilities for Resident #48, who declined in bed mobility, transfers, eating and toileting. This affected one of six (Resident's #5, #48, #75, #99, #109, and #163) reviewed for activities of daily living. The facility census was 112.
Residents Affected - Few
Findings included: Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including sarcoidosis, psychosis, symbolic dysfunction, abnormality of gait, difficulty in walking, peptic ulcer, altered mental status, insomnia, dementia with behavioral disturbance, hypertension and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required supervision for bed mobility and toileting, and she was independent with transfers and eating. Review of the 07/31/19 MDS 3.0 assessment revealed the resident required extensive assistance for bed mobility and toilet use, required supervision for transfers and limited assistance for eating. Further review of the assessment revealed the resident did not receive restorative services or therapies. Further review of the resident record did not yield documentation of restorative services or physical/occupational therapies or an assessment documenting the decline in function. Review of the physician orders did not yield orders for restorative services or physical/occupational therapies. Observation of the resident from 10/06/19 to 10/09/19 revealed the resident appeared confused, wandered aimlessly through out the secure floor and utilized a low bed. Interview on 10/08/19 at 3:47 P.M. with Licensed Practical Nurse (LPN) #16, the MDS coordinator, she stated that the time frame for looking at the resident is a seven-day period, and due to the residents diagnosis of dementia she may have fluctuated and needed more assistance on those days, but she had not changed. Review of the May 2019 MDS 3.0 assessment and revealed the decline had begun there with no intervention. The surveyor questioned why restorative was not started when the resident began to decline, she stated they did not have restorative. Review of the activity of daily living (ADL) care plan revealed no documentation of the stated fluctuation of functional status. Interview on 10/0919 at 7:50 A.M. with State Tested Nursing Assistant (STNA) #134, she stated the resident required full care with bathing, hygiene, dressing and grooming; however, if she was set-up she was able to feed herself.
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Page 12 of 30
365594
10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
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 observation, interview and record review, the facility failed to ensure one resident (Resident #75) received nail care of five Residents (#16, #75, #99, #109, and #163) reviewed for activities of daily living (ADL). The facility census was 112.
Residents Affected - Few
Findings included: Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including, hemiplegia and hemiparesis, vascular dementia without behavior disturbance, major depression, other specific joint derangements. Review of the annual comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident required extensive assistance of one staff for personal hygiene. On 10/06/19 at 11:20 A.M. observation of the resident revealed his left arm was contracted at the wrist and elbow. The resident had full use of the right hand. The right hand was noted to have long dirty finger nails. With the contractures of the left hand, the resident would not be able to clean or clip his nails. Interview with Licensed Practical Nurse (LPN) #101 on 10/07/19 at 3:25 P.M. revealed the state tested nursing assistants (STNA's) and the nurses both do nail care, and activities does them at times. She stated it just depended on who had time. She stated she cuts Resident #75's nails personally once a month. After being informed his nails were long and dirty, she stated the STNA's were to clean them. Review of the progress notes for the last three months did not indicate the resident refused care. Review of the care plan dated 04/07/19 indicated the resident required assistance with bathing and grooming, and the nurse would assist. Review of the activity of daily living policy and procedure dated 03/2018 stated Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
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Page 13 of 30
365594
10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0685
Assist a resident in gaining access to vision and hearing services.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident #48 was provided with glasses after a vision exam indicated she required them. This effected one of one resident reviewed for vision.
Residents Affected - Few
Findings included: Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including psychosis, symbolic dysfunction, abnormality of gait, altered mental status, insomnia and dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident's vision was adequate, and she had no corrective lens. Interview on 10/06/19 at 9:38 A.M. with the residents responsible party revealed the resident was admitted with glasses, but they have disappeared. She was unsure if the resident had been seen for vision consult. Review of the resident record revealed the resident was seen for a vision exam on 11/07/18 and had a prescription for glasses. Interview on 10/08/19 at 10:18 A.M. with the Unit Nurse, Licensed Practical Nurse (LPN) #107, she stated she had never seen the resident with glasses. She stated she was not aware if the resident had glasses in her room. LPN #107 had been employed with the facility since 07/21/17 and had worked with the resident frequently. Interview on 10/08/19 at 11:04 A.M. with Licensed Social Worker (LSW) #89, the surveyor asked if the resident received glasses as a result of her 11/07/18 eye appointment, and if she didn't, why not. He stated he would have to check his notes. He stated he had documentation that the resident had received new glasses in 10/2016. When surveyor asked where the glasses were, he indicated he would search the residents room. At 2:38 P.M., LSW #89 reported he could not find the glasses. The glasses that LSW #89 reported the resident had were from 10/2016 but not did not address the lack of glasses from the eye exam dated 11/07/18. Interview on 10/09/19 at 7:50 A.M. with State Tested Nursing Assistant (STNA) #134, she indicated she had never seen the resident with glasses. STNA #134 had been employed with the facility since 06/06/19 and frequently worked with the resident. Observation and interview with Resident #48 on 10/09/19 at 9:40 A.M., the resident was in the activity room staring at the dry erase board that had the activity calendar on it, which was newspaper size print. The surveyor pointed to the word End and asked the resident if she knew what that word was. The resident lowered her face to approximately three inches from the board then looked at surveyor and giggled. The surveyor again asked the resident what the word was. The resident again lowered her face to the board to within three inches to see the word and again giggled then hugged the surveyor. The surveyor pointed to a group of three pumpkins on the bottom right of the calendar and asked the resident if she knew what they were. Again the resident lowered her face to within three inches of the calendar, then turned to look at the surveyor and smiled. The resident was not interviewable, however she consistently lowered her face towards the calendar to see the word and picture the surveyor was pointing to.
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Page 14 of 30
365594
10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0685
The resident was observed without glasses on 10/06/19 at 2:02 P.M. ,10/07/19 at 10:35 A.M., 10/07/19 at 2:38 P.M., 10/08/19 at 10:18 A.M., 10/09/19 at 7:50 A.M. and 10/09/19 at 9:40 A.M.
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
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10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0688
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident #78's right hand splint was applied correctly. This effected one of one resident reviewed for positioning. The facility census was 112.
Findings include: Review of the medical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease, hypothyroidism, dysphagia, symbolic dysfunction and cerebral vascular accident. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had moderate cognitive impairment and no splinting devices. Review of the physicians telephone orders dated 09/19/19 stated the resident was to wear bilateral resting hand splints at all times. Interview on 10/06/19 at 10:20 A.M. with the residents spouse revealed she thought the splints had been applied by the state tested nursing assistants (STNA's). The surveyor observed the resident was wearing bilateral hand splints, a left elbow pad and compression stockings. The right hand splint did not appear to be placed correctly due to the right hand fingers were curled under into his palm instead of stretched out over the the curve of the hand splint. Observation on 10/07/19 at 10:35 A.M., and 10/08/19 at 8:25 A.M. revealed the residents' right hand was curled under and not placed on the splint properly. Review of the Functional Maintenance Program in-service given by Occupational Therapy on 09/12/19 for the application of the residents splints indicated five staff were in-serviced. Interview on 10/08/19 at 8:28 A.M. with Therapy Staff #161 regarding the residents right hand splint, which is either not applied correctly or is ineffective. The splint was observed to be displaced to the point where the resident was able to ball his hand into a fist. She attempted to adjust the splint while it was on the resident, then had to remove it, stretch the residents fingers and hand then reapplied the splint. She continued to stretch the residents fingers, which insured the residents hand was open and his palm made contact with the splint and his fingers curled around the hump of the splint. She stated if the resident spasms or coughs, it could have caused the splint to dislodge. The surveyor asked Therapy Staff #161 how effective the splint was if it could be dislodge by coughing or spasms. She verified it was not effective and would have to be reassess by the therapy department. Interview on 10/08/19 at 9:01 A.M. with STNA #21, she stated they were in-serviced by the nurse on how to apply the splint, but it doesn't quite fit. She was afraid she would hurt the resident if she stretched out his fingers.
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10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0711
Level of Harm - Potential for minimal harm
Residents Affected - Some
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Based on record review and staff interview, the facility failed to ensure monthly physician's orders were signed and dated as required. This affected three (Residents #14, #111 and #114) of twenty eight residents reviewed. The facility census was 112.
Findings include: Review of the medical records for Resident's #14, #111 and #114 on 10/07/19 between 1:00 P.M. and 2:00 P.M. revealed the monthly physician's orders were not signed for April 2019, May 2019, June 2019, July 2019, August 2019 and September 2019. Corporate Nurse #400 verified the lack of signatures in an interview on 10/07/19 at 2:05 P.M.
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10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0730
Observe each nurse aide's job performance and give regular training.
Level of Harm - Minimal harm or potential for actual harm
Based on interview and review of personnel files, the facility failed to ensure performance reviews were completed every 12 months and failed to ensure State Tested Nurse Aides (STNA) completed 12 hours of in-service education every twelve months. This affected two (STNA #131 and #166) of five STNA personnel files reviewed.
Residents Affected - Few
Findings include: Review of five STNA personnel files revealed two STNA's #131 and #166 had been employed over a year. STNA #131 was hired on 01/09/00 and had no evidence of annual evaluations until this day, 10/09/19. STNA #166 was hired 01/09/13 and had no evidence of annual evaluations. Human Resource Director (HRD) #100 provided a performance evaluation indicating her date of hire was 06/06/19 and was not due for a three month evaluation until 09/02/19. Interview with HRD #100 verified annual evaluations were not completed on 10/09/19 at 4:30 P.M. Review of STNA #166's personnel file had no evidence she was provided 12 hours of in-service education annually. Interview with HRD #100 on 10/09/19 at 4:30 P.M. verified there was no documented evidence of STNA #166's in-service education.
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10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0732
Post nurse staffing information every day.
Level of Harm - Potential for minimal harm
Based on observation and staff interview, the facility failed to ensure posted nursing staff information was updated in a timely manner. This had the potential to affect all residents. The facility census was 112.
Residents Affected - Many
Findings include: Observation of the posted nursing staff information on 10/06/19 at 8:00 A.M. revealed the posted nursing staff information was from 10/04/19. Registered Nurse (RN) #128 verified the posted nursing staff information was not up to date in an interview on 10/06/19 at 8:15 A.M.
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10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a residents was discharged with the correct medication. This affected one resident (Resident #313) of three residents reviewed for discharge. The facility census was 112.
Residents Affected - Few
Findings include: Review of the closed medical record of Resident #313 revealed an admission date of 06/17/19. Her admitting diagnoses included type II diabetes, pneumonia, heart failure, hypothyroidism and atrial fibrillation. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was alert and oriented. She required supervision of one staff for most activities of daily living, including personal hygiene and toileting. Review of the discharge medications revealed she was ordered the following medications: • Amlodipine (medication to treat high blood pressure and chest pain) 10 milligrams (mg) daily • Aspirin (blood thinner) 81 mg by mouth daily • Doxazosin (medication to treat urinary retention and high blood pressure) 2 mg take one tablet by mouth daily • Ferrous Sulfate (iron supplement) 325 mg one tablet by mouth daily • Fluticasone (corticosteriod) 50 micrograms (mcg) 0.05% instill 2 sprays in each nostril once a day at 8 A.M. 12 noon, and 9 P.M. • Hydrochlorothiazide (diuretic) 25 mg one tablet one tablet my mouth • Levothyroxine (hormone)150 mcg take one tablet my mouth daily
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10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0757
•
Level of Harm - Minimal harm or potential for actual harm
Lidocaine Patch (local anesthetic) 9 % apply one patch topically to back daily. On for 12 hours off for 12 hours
Residents Affected - Few
• Linzess (medication to treat irritable bowel syndrome) 145 mcg one capsule daily by mouth • Losartan potassium (medication to treat high blood pressure) 50 mg Take one tablet my mouth daily • Pantoprazole (medication to treat gastroesophageal reflux disease) 40 mg take one tablet by mouth daily • Torrance Ophthalmic drops (lubricating eye drops) instill one drop in each eye once a day • Vitamin B12 (supplement) 1000 mcg give take one tablet by mouth daily • Vitamin D3 (supplement) 2000 units take two tablets by mouth daily • Carvedilol (medication to treat high blood pressure and heart failure) 6.25 mg take one tablet by mouth two times a day • Floraster (probiotic) 250 mg take one capsule by mouth twice a day • Topiramate (nerve pain medication and anticonvulsant) 100 mg take one tablet by mouth twice a day • Gabapentin (nerve pain medication and anticonvulsant) 300 mg take one capsule by mouth three times a day. •
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10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0757
Acetaminophen (pain medication and fever reducer) 325 mg take two tablets by mouth every 6 hours.
Level of Harm - Minimal harm or potential for actual harm
• Qvar inhaler (corticosteriod) 80 mcg inhale two puffs by mouth twice a day
Residents Affected - Few • Ofloxacin (antibiotic) 0.9% eye drops instill one drop in right eye four times a day • Prednisolone AC (steroid) 1% Instill one drop in right eye four times a day • Atorvastatin (medication to treat high cholesterol) 80 mg take one tablet by mouth at bedtime • Loratadine (antihistamine) 10 mg take one tablet by mouth at bedtime. • Novolog Flex pen for insulin coverage subcutaneous (sq) four times a day • Toujeo Solostar insulin 300 units inject 38 units sq once a day at bedtime • Trulicily (diabetic medication) 1.5 mg / 0.5 milliliter (ml) administer 1.5 ml sq once a week on Tuesday at 5 P.M. The resident not only received the above medications to take home but also received two additional medication cards, one card of Omeprazole (medication to treat gastroesophageal reflux disease) 20 mg belonging to Resident #83 and one card of Omeprazole 20 mg belonging to Resident #26. Interview with the Director of Nursing (DON) on 10/06/19 at 1:30 P.M. verified the sister of Resident #313 did return the two other resident's medication cards that Resident #313 was given to take home.
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10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0758
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review monthly pharmacy recommendations and interview, the facility failed to ensure a gradual dose reduction was attempted for Resident #108. This affected one resident (Resident #108) of five residents reviewed for unnecessary medications.
Findings include: Review of the medical record revealed Resident #108 was admitted to the facility on [DATE]. Her admitting diagnoses included urinary tract infections, sickle cell trait, gout, vascular dementia, type II diabetes and chronic kidney disease. Review of Resident #108's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment. She required extensive assistance for bed mobility, dressing, toilet use and personal hygiene. Resident #108 was totally dependent on staff for transfers and locomotion on and off the unit. Review of the medication assessment from the MDS revealed the resident received seven injections of insulin, received an antidepressant seven of seven days, an antipsychotic seven of seven days and an anticoagulant seven of seven days. Review of the Pharmacy Physician Recommendation Form dated 02/20/19 revealed a recommendation from the pharmacist requesting the physician consider reducing Resident #108's Quetiapine (antipsychotic) to 25 milligrams one time a day. The physician agreed to attempt a dose reduction on 02/26/19. Review of physician orders from February 2019 to present revealed no order for an attempted gradual dose reduction of Quetiapine. Review of the resident's medication administration record (MAR) revealed the resident continued to receive Quetiapine 25 mg two times a day from February 2019 to present.
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10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0812
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Based on observation and interview, the facility failed to ensure staff washed their hands between handling soiled floor mats and clean steam table pans. This had the potential to affect 105 residents out of a census of 112. Residents #27, #47, #61, #65, #69, #86 and #106 did not receive receive meals from the kitchen.
Findings included: During the dinner tray line observation on 10/05/19 at 5:25 P.M. Staff #66 was noted to pick-up two debris laden rubber floor mats off of the floor and take them to the back of the kitchen near the dirty dish area. He then sprayed the mats down and put them back near the tray line. The mats still contained debris. He then placed three clean steam table pans beneath the steam table onto a stack of other clean pans without first washing his hands. This observation was verified with the Dietary Manager (DM) at the time of the observation. The DM removed the pans and placed them in the dirty dish area.
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10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0838
Level of Harm - Potential for minimal harm
Residents Affected - Many
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Based on record review and staff interview, the facility failed to ensure the facility assessment contained all required information. This had the potential to affect all residents. The facility census was 112.
Findings Include: Review of the facility assessment revealed the following: • All of the documentation in the assessment was on the previous owners letter head. • The census information contained in the assessment was out of date (from October 2018). • Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies were noted to be for the previous owners of the facility, and no updated contracts were noted. Interview with the Administrator on 10/6/19 at 10:45 A.M. verified the above findings.
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10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm or potential for actual harm
Based on record review and staff interview, the facility failed to ensure the medical director was an active participant of the Quality Assurance (QA) Committee. This had the potential to affect all residents. The facility census was 112.
Residents Affected - Many
Findings include: Review of the facilities sign-in sheet for the QA meeting minutes for the meetings held in June 2019, July 2019, August 2019 and September 2019 revealed no evidence the medical director attended the meetings. Interview with the Administrator on 10/09/19 at 3:25 P.M. verified the medical director did not attend the QA meetings as required.
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10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure appropriate hand washing was performed during care of a resident on isolation precautions, personal protective equipment was properly disposed of, proper signage was posted regarding the need for isolation precautions, and biohazardous waste was properly disposed of. This affected one (Resident #43) of one resident reviewed for isolation precautions and had the potential to affect all 112 residents currently residing in the facility.
Residents Affected - Many
Findings include: Resident #43 was admitted to the facility on [DATE] with diagnoses including dementia and a Clostridium Difficile (a highly contagious bacteria) infection of the stool. A Minimum Data Set Assessment 3.0 (MDS) dated [DATE] revealed she had severe cognitive impairment, and needed extensive assistance for most activities of daily living including toileting. She was totally dependent on staff for transfers and eating. Review of physician orders dated 09/24/19 revealed Resident #43 was ordered to be placed on contact isolation precautions regarding a diagnosis of Clostridium Difficile infection of the stool. 1. Observation on 10/06/19 at 4:30 P.M. revealed two State Tested Nursing Assistants (STNA) #143 and #20 coming out of Resident #43's room. Both STNAs removed their personal protective equipment (disposable gloves and gowns) placed them in the trash, and exited the room without washing their hands. STNA #143 and STNA #20 then proceeded to use the hand sanitizer dispenser mounted on the wall. On 10/06/19 at 4:40 P.M. STNA #20 and STNA #143 verified they should have washed their hands before leaving Resident #43's room. 2. On 10/07/19 at 7:30 A.M. observation of Resident #43's room revealed there was no sign posted on the door to alert visitors and staff of the need for isolation precautions and used personal protective equipment was laying on the floor next to an overflowing trash can. On 10/07/19 at 7:50 A.M. Licensed Practical Nurse (LPN) #301 verified the lack of a sign on the door indicating isolation precautions were necessary before entering and the trash can was overflowing. 3. Observation of Resident #43's room on 10/07/19 at 9:00 A.M. revealed a clear plastic bag in the corner of the room that contained contaminated personal protective equipment such as used gloves. Interview with Housekeeping Assistant (HA) #3 on 10/07/19 at 9:40 A.M. revealed the clear plastic bag with used gloves and other miscellaneous items was trash that she'd double bagged for disposal. When asked where the trash from the isolation room was disposed of, HA #3 said she took it to the dumpster. When asked what the facility policy was for disposal of biohazardous waste, she stated she was to put it in the dumpster. Interview with HA #82 on 10/07/19 at 10:50 A.M. regarding proper disposal of biohazardous waste revealed she placed trash from isolation rooms in a clear trash bag and took the bag to the dumpster. When asked if that was the facility policy on disposing of contaminated waste, she stated that it was.
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10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0880
Level of Harm - Minimal harm or potential for actual harm
Interview with Housekeeping Manager (HM) #6 on 10/07/19 at 12:50 P.M. revealed she had just inserviced staff on infection control. HM #6 stated staff were educated that biohazardous waste, such as bags of trash from Resident #43's room, was to be placed in a red biohazard bag and should not be disposed of in the dumpster, but in a special container located in the basement.
Residents Affected - Many
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10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0921
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Based on observation and staff interview the facility failed to ensure the envionment was manintained in a clean manner and in good repair for all residents. This affected 27 (Residents #9, #10, #11, #12, #22, #34, #35, #55, #56, #57, #58, #61, #62, #65, #68, #69, #80, #86, #87, #93, #96, #97, #98, #99, #112, #163 and #365) of 112 residents currently residing in the facility.
Findings include: An environmental tour was conducted on 10/09/19 between 9:45 A.M. and 10:33 A.M. with Housekeeping Supervisor (HSK) #6 and Maintenance Director (MD) #15. The following concerns were observed and verified during the tour by HSK #6 and MD #15; • The room belonging to Residents #10 and #93 contained a stained privacy curtain. • The room belonging to Residents #56 and #62 contained multiple holes in the walls. • The rooms belonging to Residents #69 and #97 contained tube feeding poles with a significant amount of dried and caked on tube feeding liquid. • The room belonging to Resident #99 contained bed sheets with large stains of unknown substances. • The rooms belonging to Residents #9, #65, #68 and #96 contained splotches on the ceiling of an unknown brown substance. • The room belonging to Resident #163 contained residue on the floor coming from a portion of the ceiling that was crumbling. • The rooms belonging to Residents #61 and #112 contained wall paper peeling off multiple areas of the walls. •
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10/09/2019
Gardens of Euclid Beach
16101 Euclid Beach Blvd Cleveland, OH 44110
F 0921
The room belonging to Residents #12, #22 and #57 contained a cracked bathroom floor.
Level of Harm - Minimal harm or potential for actual harm
• The room belonging to Resident #34 contained a broken cover to the phone cord with exposed wires.
Residents Affected - Some • The rooms belonging to Residents #34 and #55 contained caulking around the bathroom sink that was brown in color and peeling. • The room belonging to Resident #365 contained a overpowering odor of an unknown source. • The rooms belonging to Residents #80, #86, #87 and #98 contained air conditioning units that were dirty and had multiple broken levers and vents. • The room belonging to Resident #35 contained an air vent located above the bed that was brown in color. • The room belonging to Residents #86 and #98 contained a heater cover that was dislodged and on the floor. • The room belonging to Residents #11 and #58 contained a bathroom baseboard that was coming off the wall.
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Back to topCitations
23 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.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F553 - The right to participate in the development and implementation of his or her
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
F577 - The resident has the right to-
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F660 - Quality of life
Plan the resident's discharge to meet the resident's goals and needs.
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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.
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F711 - Physician Visits
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F838 - Facility assessment
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F880 - Infection Control
Provide and implement an infection prevention and control program.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the October 9, 2019 survey of GARDENS OF EUCLID BEACH?
This was a inspection survey of GARDENS OF EUCLID BEACH on October 9, 2019. The surveyor cited 23 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GARDENS OF EUCLID BEACH on October 9, 2019?
Yes, 23 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."
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.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.