Inspection visit
Health inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview the facility failed to ensure Resident #48 was treated with respect and dignity.
This affected one resident (#48) of one resident reviewed for resident rights. The facility census was 58.
Findings include:
Record review revealed Resident #48 was re-admitted to the facility on [DATE] with diagnoses that included
ataxia, muscle weakness, and unspecified mood disorder.
Review of a progress note dated 02/14/23 at 12:05 P.M. revealed Resident #48 requested assistance
regarding Social Security benefits from Former Social Services (FSS) #900. FSS #900 changed the time
for Resident #48 to meet with her and Resident #48 became verbally aggressive. FSS #900 informed
Resident #48 she was disrespectful, and her behavior was unacceptable.
Review of a progress note dated 02/15/23 at 11:00 A.M. revealed Resident #48 went to FSS #900's office
and asked if they were going to continue to work on her Social Security benefits by stating are we going to
make the call or what. FSS #900 told Resident #48 that unless she apologized for her behavior the previous
day, she would not assist her.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/29/23 revealed Resident #48
was alert and oriented to person, place, time, and required one-person assist for activities of daily living
(ADL) care.
Interview on 04/04/23 with Resident #48 revealed she had not received assistance with her Social Security
benefits. Resident #48 revealed FSS #900 did not like her and always ignored her request. Resident #48
revealed she attempted to start the process on her social security benefits so she could discharge home.
Interview on 04/05/23 at 9:19 A.M. with Social Work Director (SWD) #533 revealed she was aware
Resident #48 required assistance with her social security benefits but had not been assisted as of the time
of the annual survey.
Interview on 04/06/23 at 8:48 A.M. with the Administrator and Director of Nursing (DON) verified the above
findings. Interview also revealed FSS #900 was no longer employed at the facility. The administrative staff
indicated they were unaware of the interactions between FSS #900 and Resident #48, despite it being
documented in the resident's electronic medical record.
(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 11
Event ID:
365594
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
365594
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of Euclid Beach
16101 Euclid Beach Blvd
Cleveland, OH 44110
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)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility document titled Dignity revised February 2021, revealed residents would be treated
with dignity and respect, and staff would speak respectfully to residents, at all times.
This deficiency represents non-compliance investigated under Complaint Number OH00141540.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365594
If continuation sheet
Page 2 of 11
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
365594
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of Euclid Beach
16101 Euclid Beach Blvd
Cleveland, OH 44110
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)
F 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Many
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview the facility failed to ensure the State Ombudsman was notified of resident
transfers to the hospital. This affected three residents (#4, #19 and #164) and had the potential to affect all
58 residents residing in the facility.
Findings include:
1. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including
spondylosis, malnutrition, chronic obstructive pulmonary disease, major depressive, dementia,
hypertension, irritable bowel syndrome, insomnia, incisional hernia, dysthymic disorder (mild form of
depression), colon cancer, and migraine.
Review of the nursing progress note dated 02/17/23 at 1:43 P.M. revealed Resident #4 was admitted to the
hospital for suicidal ideations.
Review of the electronic medical record revealed no evidence the State Ombudsman was notified of
Resident #4's transfer to the hospital.
Interview with the Administrator on 04/04/23 at 6:30 P.M. confirmed the facility did not notify the State
Ombudsman of Resident 4's transfer to the hospital.
Review of the facility's undated policy titled Transfer and Discharge (including AMA [agains medical advice])
revealed the facility would maintain evidence the notice of transfer and/or discharge was sent to the
ombudsman.
2. Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses that included
hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease, and type
two diabetes mellitus.
Review of nursing progress notes dated 03/28/23 timed 8:22 P.M. and 03/29/23 timed 3:38 A.M. revealed
Resident #19 was sent out and subsequently admitted to the local hospital for a kidney infection.
Review of the electronic medical record revealed no evidence the State Ombudsman was notified of
Resident #19's transfer to the hospital.
Interview with the Administrator on 04/04/23 at 6:30 P.M. confirmed the facility did not notify the State
Ombudsman of Resident 19's transfer to the hospital.
Review of the facility's undated policy titled Transfer and Discharge (including AMA [agains medical advice])
revealed the facility would maintain evidence the notice of transfer and/or discharge was sent to the
ombudsman.
3. Record review revealed Resident #164 was admitted to the facility on [DATE] with diagnoses including
syringomyelia/syringobulbia (fluid filled cyst on spinal cord), hemiplegia/hemiparesis, stroke, epilepsy,
chronic obstructive pulmonary disease, asthma, diabetes, morbid obesity, aphasia following stroke, major
depressive, schizophrenia, and bipolar.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365594
If continuation sheet
Page 3 of 11
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
365594
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of Euclid Beach
16101 Euclid Beach Blvd
Cleveland, OH 44110
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)
F 0623
Level of Harm - Potential for
minimal harm
Review of nursing progress note dated 03/20/23 timed 4:08 P.M. revealed Resident #164 was sent out and
subsequently admitted to the hospital for suicidal ideation and self-harm.
Review of the electronic medical record revealed no evidence the State Ombudsman was notified of
Resident #164's transfer to the hospital.
Residents Affected - Many
Interview with the Administrator on 04/04/23 at 6:30 P.M. confirmed the facility did not notify the State
Ombudsman of Resident 164's transfer to the hospital.
Review of the facility's undated policy titled Transfer and Discharge (including AMA [agains medical advice])
revealed the facility would maintain evidence the notice of transfer and/or discharge was sent to the
ombudsman.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365594
If continuation sheet
Page 4 of 11
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
365594
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of Euclid Beach
16101 Euclid Beach Blvd
Cleveland, OH 44110
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)
F 0645
PASARR screening for Mental disorders or Intellectual Disabilities
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 staff interview the facility failed to ensure Resident #48 was screened for services and
placement in the nursing facility. The facility also failed to notify the appropriate State agency (the Ohio
Department of Mental Health) when two residents (#4 and #48) with a level two mental illness had a
significant change in condition. This affected two residents (#4 and #48) of two residents reviewed for
Pre-admission Screen and Resident Review (PASARR). The facility census was 58.
Residents Affected - Few
Findings include:
1. Record review revealed Resident #48 was re-admitted to the facility on [DATE] with diagnoses that
included ataxia, muscle weakness, and unspecified mood disorder.
Review of a PASARR evaluation dated 01/04/23 revealed Resident #48 had a level two mental illness. In
addition, the PASARR result notice dated 01/04/23 revealed a referral was made for a level two evaluation.
Further review of Resident #48's hard chart and electronic medical record (EMR) revealed no level two
evaluation results.
Review of the progress note dated 03/20/23 timed 4:30 P.M. revealed Resident #48 was sent out to and
subsequently admitted to a local psychiatric hospital.
Review of Resident #48's electronic medical record (EMR) revealed Resident #48 returned to the facility on
[DATE]. There was no evidence the Ohio Department of Mental Health was notified of Resident #48's
admission to the psychiatric hospital.
Review of the quarterly, Minimum Data Set (MDS) assessment, dated 03/29/23 revealed Resident #48 was
alert and oriented to person, place, time, and required a one-person assist for activities of daily Living
(ADLs).
Interview with the Administrator on 04/04/23 at 11:00 A.M. confirmed the lack of notification to the Ohio
Department of Mental Health for Resident #48.
Interview with Social Work Director (SWD) #533 on 04/05/23 at 9:19 A.M. confirmed the above findings.
Resident #48 required a significant change PASARR and level two evaluation which were not completed as
required.
2. Record review revealed Resident #4 was admitted to the hospital on [DATE] for suicidal ideations.
Resident #4 had diagnoses including spondylosis, malnutrition, chronic obstructive pulmonary disease,
major depressive, dementia, hypertension, irritable bowel syndrome, insomnia, incisional hernia, dysthymic
disorder (mild form of depression), colon cancer, and migraine.
Review of the PASARR evaluation dated 02/06/23 revealed Resident #4 had a level two mental illness.
Review of the EMR revealed Resident #4 returned to the facility on [DATE]. There was no evidence the
facility notified the Ohio Department of Mental Health of Resident #4's admission to the psychiatric hospital.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365594
If continuation sheet
Page 5 of 11
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
365594
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of Euclid Beach
16101 Euclid Beach Blvd
Cleveland, OH 44110
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)
F 0645
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview with the Administrator on 04/04/23 at 11:00 A.M. confirmed the lack of notification to the Ohio
Department of Mental Health for Resident #4.
Interview with Social Work Director (SWD) #533 on 04/05/23 at 9:19 A.M. confirmed the above findings.
Resident #4 required a significant change PASARR and level two evaluation which were not completed as
required.
This deficiency represents non-compliance investigated under Complaint Number OH00141540.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365594
If continuation sheet
Page 6 of 11
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
365594
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of Euclid Beach
16101 Euclid Beach Blvd
Cleveland, OH 44110
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)
F 0745
Provide medically-related social services to help each resident achieve the highest possible quality of life.
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 Resident #48 received timely assistance with
applying for Social Security benefits from social service staff. This affected one resident (#48) of one
resident reviewed for resident rights. The facility census was 58.
Residents Affected - Few
Findings include:
Record review revealed Resident #48 was re-admitted to the facility on [DATE] with diagnoses that included
ataxia, muscle weakness, and unspecified mood disorder.
Review of a progress note dated 02/14/23 at 12:05 P.M. revealed Resident #48 requested assistance
regarding Social Security benefits from Former Social Services (FSS) #900. FSS #900 changed the time
for Resident #48 to meet with her and Resident #48 became verbally aggressive. FSS #900 informed
Resident #48 she was disrespectful, and her behavior was unacceptable.
Review of a progress note dated 02/15/23 at 11:00 A.M. revealed Resident #48 went to FSS #900's office
and asked if they were going to continue to work on her Social Security benefits by stating are we going to
make the call or what. FSS #900 told Resident #48 that unless she apologized for her behavior the previous
day, she would not assist her.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/29/23 revealed Resident #48
was alert and oriented to person, place, time, and required one-person assist for activities of daily living
(ADL) care.
Interview on 04/04/23 with Resident #48 revealed she had not received assistance with her Social Security
benefits. Resident #48 revealed FSS #900 did not like her and always ignored her request. Resident #48
revealed she attempted to start the process on her social security benefits so she could discharge home.
Interview on 04/05/23 at 9:19 A.M. with Social Work Director (SWD) #533 revealed she was aware
Resident #48 required assistance with her social security benefits but had not been assisted as of the time
of the annual survey.
Interview on 04/06/23 at 8:48 A.M. with the Administrator and Director of Nursing (DON) verified the above
findings. Interview also revealed FSS #900 was no longer employed at the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365594
If continuation sheet
Page 7 of 11
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
365594
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of Euclid Beach
16101 Euclid Beach Blvd
Cleveland, OH 44110
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.
Observation of medication cart 1 on 04/04/23 at 1:36 P.M. revealed 43 loose unidentifiable medications at
the bottom of the drawers.
Interview during the observation with Licensed Practical Nurse (LPN) #580 verified the findings.
3. Observation of medication cart 2 on 04/04/23 at 1:50 P.M. revealed 30 loose unidentifiable medications at
the bottom of the drawers.
Interview during the observation with LPN #579 verified the findings.
4. Observation of medication cart 3 on 04/04/23 at 2:15 P.M. revealed 44 loose unidentifiable medications at
the bottom of the drawers.
Interview during the observation with LPN #579 verified the findings.
5. Review of medical record for Resident #15 revealed an admission date of 11/23/21. Diagnoses included
type two diabetes mellitus with diabetic peripheral angiopathy without gangrene.
Review of plan of care dated 12/23/21 revealed Resident #15 had diabetes. Review of the medication
administration record revealed Resident #15 was ordered 19 units of Humalog solution (11/29/21) before
meals and 10 units of Glargine solution (11/29/21) at bedtime.
On 04/04/23 at 2:15 P.M. observation of cart 3 revealed an opened vial of Lantus insulin for Resident #15
which was not dated.
Interview during the observation with LPN #579 verified the findings.
6. Review of medical record for Resident #51 revealed an admission date of 08/12/22. Diagnoses included
type two diabetes mellitus, long term use of insulin, and sarcoidosis of the lung.
Review of the medication administration record revealed Resident #51 was ordered 20 units of Novolog
flexpen solution (09/23/22) at bedtime.
On 04/04/23 at 2:15 P.M. observation of cart 3 revealed an insulin flexpen for Resident #51 that was not
dated.
In addition, observation of the medication cart revealed an opened insulin vial of Humulin and Glargine with
no resident name or date opened documented.
Interview during the observation with LPN #579 verified the findings.
7. Observation of medication cart 4 on 04/04/23 at 1:36 P.M. revealed 41 loose unidentifiable medications at
the bottom of the drawers.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365594
If continuation sheet
Page 8 of 11
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
365594
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of Euclid Beach
16101 Euclid Beach Blvd
Cleveland, OH 44110
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)
F 0761
Interview during the observation with LPN #583 verified the findings.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility policy titled Medication Administration, dated 2021 revealed staff were to maintain a
clean an organized medication cart.
Residents Affected - Many
This deficiency represents non-compliance investigated under Complaint Number OH00141540.
Based on observation, record review and interview the facility failed to ensure medications were stored in a
secure manner and medications where labeled with residents' names and date opened. This affected three
residents (#48, #15 and #51) and had the potential to affect all 58 residents in the facility who received
medications from medication carts 1, 2, 3 and 4.
Findings include:
1. Record review revealed Resident #48 was re-admitted to the facility on [DATE] with diagnoses that
included ataxia, muscle weakness, and unspecified mood disorder.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/29/23 revealed Resident #48
was alert and oriented to person, place, time and required a one-person assist for activities of daily living.
Observation on 04/04/23 at 8:18 A.M. of Resident #48's bedside table revealed two unidentified white pills,
circular in shape, sitting in a small plastic cup.
Interview on 04/04/23 at 8:18 A.M. with Resident #48 revealed she was provided the pills by overnight staff
but did not take them. Resident #48 revealed staff did not monitor if she swallowed the pills or not.
Interview on 04/04/23 at 8:33 A.M. with State Tested Nursing Assistant (STNA) #584 confirmed the two
identified white pills sitting on Resident #48's bedside table.
Interview on 04/04/23 at 8:50 A.M. with Registered Nurse (RN) #517 revealed pills should not be left at the
bedside and residents should be monitored during administration.
Observation on 04/04/23 at 8:50 A.M. revealed RN #517 entered Resident #48's room and removed the
pills.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365594
If continuation sheet
Page 9 of 11
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
365594
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of Euclid Beach
16101 Euclid Beach Blvd
Cleveland, OH 44110
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)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
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 interview the facility failed to maintain a safe and sanitary environment for
residents. This affected five residents (#10, #16, #21, #54 and #164) of 58 residents residing in the facility.
Residents Affected - Many
Findings include:
1. On 04/04/23 from 9:45 A.M. to 10:05 A.M. environmental observations revealed the following concerns:
Resident #10 had approximately 10 strips of clothing/fabric hanging over the electrical outlet and the
baseboard heating unit of the room.
The base baseboard molding located by Resident #16's headboard was peeled back and hanging from the
wall. There was also a drywall patch behind the headboard that needed sanding; the drywall plaster was
uneven and spread haphazardly over the patch.
Observation of Resident #21 and #54's room revealed the baseboard heater did not have a cover over the
heating elements.
On 04/04/23 at 1:38 P.M. interview with the Administrator and Maintenance staff verified the above findings.
2. On 04/03/23 at 10:37 A.M. Resident #164's privacy curtain was observed to have dark brown stains and
splatter marks on the left bottom corner.
On 04/03/23 at 10:40 A.M. interview and observation with Housekeeper #503 confirmed the curtain stains
and splatter marks.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365594
If continuation sheet
Page 10 of 11
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
365594
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens of Euclid Beach
16101 Euclid Beach Blvd
Cleveland, OH 44110
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)
F 0926
Have policies on smoking.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview, the facility failed to implement safe and responsible smoking
practices and policies. This affected one resident (#48) of one resident reviewed for smoking and had the
potential to affect all 58 residents residing in the facility.
Residents Affected - Many
Findings include:
1. Record review revealed Resident #48 was re-admitted to the facility on [DATE] with diagnoses that
included ataxia, muscle weakness, and unspecified mood disorder.
Review of a smoking safety screen assessment. dated 12/19/22 revealed Resident #48 was safe to smoke
without supervision upon admission. Further review of the assessment revealed Resident #48 required
supervision to smoke during assigned smoke breaks, although she was an independent smoker.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/29/23 revealed Resident #48
was alert and oriented to person, place, time, and required one-person assist for activities of daily living.
Review of the care plan dated 04/01/23 revealed Resident #48 was found smoking in her room on
02/06/23.
Observation of Resident #48's room on 04/04/23 at 8:18 A.M. revealed a green lighter located on Resident
#48's bedside table and a white lighter located near the sink adjacent to her bed.
Interview with State Tested Nursing Assistant #584 at the time of observation verified the resident had a
lighter in her room.
2. Observation on 04/03/23 at 11:38 A.M. revealed more than 10 cigarette butts in the courtyard's
combustible trash containers. Further observation revealed ash trays and metal containers with self-closing
cover devices were available in the courtyard.
Interview with the maintenance director verified this finding at the time of observation. The maintenance
director verified the courtyard was a smoking area and residents should not be placing butts in the trash
container.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365594
If continuation sheet
Page 11 of 11
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Back to topCitations
7 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.
F926 - Establish policies, in accordance with applicable Federal, State, and
Have policies on smoking.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
F745 - The facility must provide medically-related social services to attain or
Provide medically-related social services to help each resident achieve the highest possible quality of life.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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 April 6, 2023 survey of GARDENS OF EUCLID BEACH?
This was a inspection survey of GARDENS OF EUCLID BEACH on April 6, 2023. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GARDENS OF EUCLID BEACH on April 6, 2023?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have policies on smoking."
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.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.