Inspection·July 26, 2023

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, record review, interview, and facility policy review, the facility failed to ensure the physical environment was maintained in a clean and sanitary manner. This affected three residents (#28, #31 and #52) and had the potential to affect additional residents residing on the Over the Falls, Sycamore, and Pier units. The facility census was 56. Findings include: On 07/26/23 environmental observations revealed the following: a. On 07/26/23 at 9:30 A.M. observation of Resident #28 and #52's room revealed the floor was dirty and sticky with visible track marks from Resident #52's power wheelchair. Observation revealed dirty linen, clothes, trash, food, and debris on the floor, on the resident's bed, under the bed, and at the entrance of the doorway. Interview on 07/26/23 at 9:35 A.M. with Staff Member (SM) #800 confirmed the condition of Resident #28 and #52's room as noted above. During the interview, SM #800 revealed the dirt on the floor came from the wheels of Resident #52 wheelchair. SM #800 verified the open boxes of cereal had been spilled onto the floor, old food boxes and food had likely been on the floor for days, and the presence of dirty and soiled linen piled on the bed and under the bed. Resident #52 bed had a small spot clear of debris for sleeping. b. On 07/26/23 at 9:45 A.M. observation of the second floor shower room located on the Sycamore unit, revealed dirty linen with visible brown stains on the washcloths and brown substance smeared on the floor, an open bag of dirty linen spilling onto the floor, and trash and debris. This shower room was noted to be used for resident showers. Interview on 07/26/23 at 9:45 A.M. with SM #801 confirmed the above findings of the shower room. SM #801 also indicated staff had assigned rooms to clean, but due to how staff were scheduled, some rooms/areas had not been cleaned for the prior two days. c. On 07/26/23 at 9:51 A.M. observation of Resident #31's room, located on the Over the Falls unit, revealed the floor was dirty and sticky with open and crushed grape jelly packets into the floor, and a soiled brief on the floor adjacent to the bed. Interview on 07/26/23 at 9:52 A.M. with SM #802 confirmed the condition of Resident #31's room as noted above. (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 2 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 07/26/2023 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)