Health inspection·December 5, 2023

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 observation, staff interviews, facility policy review and review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of COVID-19, the facility failed to maintain proper infection control procedures to prevent the spread of infection. This affected one resident (#21) and had the potential to affect fifteen residents (#5, #9, #17, #18, #19, #22, #23, #26, #29, #32, #33, #35, #40, #42, #44) who resided on the Sycamore Unit (rooms 202 through 213). The facility census was 57. Residents Affected - Few Findings include: Review of the medical record for Resident #21 revealed an admission date of 06/17/21 with diagnoses including type II diabetes, hemiplegia and hemiparesis following cerebral infarction, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #21 was alert and oriented to person, place, and time. Review of the care plan dated 10/31/23 revealed Resident #21 had signs and symptoms of coronavirus (COVID-19) positive coronavirus testing positive. Interventions included preventing the spread of infection to others, placing in isolation, and staff to wear personal protective equipment (PPE) during all care. Review of the current immunization record revealed Resident #21 was up to date for all COVID-19 related immunizations. Review of the physician orders dated 12/01/23 revealed Resident #21 had an order in place for droplet isolation precautions, gown, gloves, N95 mask, and face shield required every shift for COVID-19 positive. Review of the progress note dated 12/01/23 at 12:33 P.M. revealed a COVID-19 test was performed on Resident #21 with positive results. Resident #21 had no symptoms and was in bed resting comfortably with a call light in reach. Resident #21 was placed on isolation precautions. Interview on 12/04/23 at 8:43 A.M. with Assistant Director of Nursing (ADON) #825 revealed Resident #21 tested positive for COVID-19. Observation on 12/04/23 at 8:43 A.M. revealed a PPE bin outside of Residents #21 room that included masks, gloves, and gowns. (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 12/05/2023 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)