Health inspection·January 18, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide adequate supervision to prevent the elopement of a resident. This affected one (Resident #100) of one resident reviewed for elopement. The facility census was 99. Findings include: Review of the medical record for Resident #100 revealed an admission date of 11/30/23 with diagnosis including diabetes mellitus, depression and COVID-19. His medical record contained a photograph so that he was identifiable to staff. He was discharged to the hospital on [DATE]. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #100 had impaired cognition. Review of Resident #100's Skilled Nursing Summary dated 12/27/23 revealed the resident's gait was unsteady, had a balance problem, and required ambulatory assistance of one. Review of Resident #100's plan of care revealed the resident had impaired cognitive process for daily decision making and was at risk for further decline in cognitive status. Interventions included but were not limited to reorient and redirect as needed. Review of the elopement timeline for Resident #100 revealed on 01/06/24 at 9:30 P.M. the resident was last seen by Social Services Designee #203 at approximately 9:30 P.M. in the area of his room and nurse's station. At 9:45 P.M., Receptionist #209 let Resident #100 out of the building when other visitors exited. At 10:10 P.M. nursing staff were unable to locate Resident #100 and a search was initiated. At 10:15 P.M., staff found Resident #100 outside by the building and dumpster area with his coat and shoes on. Review of the incident report dated 01/06/24 at 10:07 P.M. revealed Resident #100 was not seen for his nighttime medication. Social services stated she had seen him on another unit visiting other residents. The nursing staff called an elopement code to look for the resident. The staff found the resident outside by the dumpster. Resident #100 had no complaints and stated he was fine. No injuries were noted. Review of the statement dated 01/06/24 by Receptionist #209 revealed she was sitting at the reception desk when she opened the door for a resident's family and a few other visitors. She stated she accidentally let Resident #100 out of the facility. She stated she had never seen him before and he (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: 365828 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 365828 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122 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)