Health inspection·February 22, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and review of cleaning schedules, the facility did not ensure residents were sitting in clean wheelchairs. This affected four residents (#14, #15, #29 and #47) out of 66 residents utilizing wheelchairs. The facility census was 94. Findings include: On 02/21/24 between 10:00 A.M. and 12:00 P.M. during the tour of the facility, Residents #14, #15, #29 and #47 were observed to be sitting in wheelchairs. Each chair had a buildup of dirt on the frame. Interview with the Director of Nursing (DON) verified the dirt buildup on each wheelchair at the time of the tour. Interview on 02/21/24 during the tour, the DON stated that wheelchairs were to be cleaned two times weekly. A review of the cleaning schedule revealed wheelchairs were to be cleaned two times weekly on Monday and Wednesday on night shift. This deficiency represents noncompliance investigated under Complaint Number OH00151189. Page 1 of 5 365828 365828 02/22/2024 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, schedule review, and policy review the facility did not ensure sufficient nursing staff to provide nursing and related services to assure resident safety when two of four nurses left the building for lunch at 12:00 A.M. on 02/05/24 and did not return until 4:30 A.M. (4.5 hours). This had the potential to affect 37 residents (#2, #3, #4, #7, #10, #12, #13, #11, #18, #19, #28, #30, #34, #38, #44, #47, #49, #50, #52, #54, #53, #56, #57, #60, #62, #66, #70, #71, #76, #80, #81, #86, #88, #89, #93, #91, and #97) residing on the units assigned to the two nurses. The facility census was 94. Findings Include: A review of the facility assessment dated [DATE] revealed the facility will be staffed with three to four nurses per shift. A review of staffing sheets dated 02/04/24 revealed Licensed Practical Nurse (LPN) #234 was scheduled from 7:00 P.M. until 7:00 A.M. the following day for unit 1 North. LPN #235 was scheduled from 7:00 P.M. until 7:00 A.M. on the 60/90 unit. LPN #214 was scheduled from 7:00 P.M until 7:00 A.M. on the 70/80 unit. LPN #164 was scheduled on the 2 North unit. On 02/21/24 at 9:24 A.M. an interview with the Director of Nursing (DON) revealed that on 02/05/24 at 7:00 A.M. she was notified that LPN #234 and LPN #235 left the building at approximately midnight and did not return to the facility until 4:30 A.M. The times were confirmed by camera. The staff is permitted to clock out and leave for 30 minutes for lunch. On 02/21/24 at 2:36 P.M an interview with the Administrator revealed he was notified of LPN #234 and LPN #235 leaving the building from midnight to 4:30 A.M. on 02/05/24. On 02/21/24 at 4:05 P.M. an interview with State Tested Nurse Aide (STNA) #171 revealed he was working on 02/04/24 from 11:00 P.M. until 7:00 A.M. At 3:30 A.M. on 02/05/24 he found Resident #91 on the floor and could not find LPN #234 assigned to the unit. STNA #171 stated he called for LPN #214 to assist. There were no injuries. STNA #171 revealed he did not see LPN #234 until 4:30 A.M. The deficient practice was corrected on 02/07/24 when the facility implemented the following corrective actions: • On 02/05/24, LPN #234 and LPN #235 were terminated. A review of the employee files verified the terminations. • On 02/05/07, the DON reported LPN #234 to the Ohio Board of Nursing. A confirmation email dated 02/07/24 revealed confirmation of the filing. 365828 Page 2 of 5 365828 02/22/2024 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0725 • Level of Harm - Minimal harm or potential for actual harm On 02/07/24, the DON in-serviced all staff on elder abuse. The in-service included abandonment, leaving the unit or assigned area without proper notification and hand off of keys and reporting to covering or oncoming nurse. Residents Affected - Some This deficiency represents noncompliance investigated under Complaint Number OH00151189. 365828 Page 3 of 5 365828 02/22/2024 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation and interview the facility failed to ensure Resident #54 received meals according to documented food preferences. This affected one resident (#54) of three residents investigated for food preferences. The facility census was 94. Findings Include: Record review for Resident #54 revealed an admission date of 02/05/24 with diagnoses including vascular dementia, depression, epilepsy, anxiety, diabetes mellitus type II, and hemiplegia following a cerebral vascular accident (CVA). Resident #54's diet orders included a regular diet with low concentrated sweets. Review of a dietary admission note dated 02/15/24 included Resident #54 disliked pork and ground meat. Review of the nurse practitioner notes dated 02/19/24 revealed Resident #54 does not eat pork or beef. The nurse practitioner instructed nursing to inform the kitchen. Interview with the Director of Nursing (DON) on 02/22/24 at 9:00 A.M. revealed resident food preferences were honored. On 02/22/24 at 9:30 A.M. an interview with Director of Dietary Services #118 revealed resident food preferences were honored, and that she interviews residents to know their likes and dislikes. Menu tickets were marked with dislikes and allergies. There was an at your request menu that residents can order from at any time. Director of Dietary Services #118 stated she was aware Resident #54 disliked pork. Observation on 02/22/24 at 12:45 P.M. revealed Resident #54 eating lunch that included a plate of roasted pork, mashed potatoes, and broccoli. The menu ticket on the food tray indicated no pork. There was not an alternative noted. An interview at the time of the observation revealed Resident#54 was upset. He stated he had told multiple staff he does not eat pork. This deficiency represents non-compliance investigated under Master Complaint Number OH00151321. 365828 Page 4 of 5 365828 02/22/2024 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

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 staff interview, the facility failed to ensure its kitchen area was maintained in a clean and sanitary manner. In addition, the facility did not ensure that food was plated to be served in a sanitary manner. This had the potential to affect all 94 residents receiving food from the kitchen. There were no residents residing in the facility not receiving food from the kitchen. Findings Include: Observation on 02/21/24 at 10:05 A.M. a tour of the kitchen was conducted with the Director of Nursing (DON). The floor had dirt and food buildup. There was also a buildup of dirt under the steam table where food was served from. The dirty floor was verified with the DON at the time of the tour. The inside of the drawer holding the serving and cooking utensils had dirt and grease buildup. The surface of the drawer had a greasy texture. The DON verified the dirty utensil drawer at the time of the kitchen tour. Dietary Manager (DM) #118 was observed packing brown bag lunches for dialysis residents. DM #118 did not have a hairnet on. The DON verified the absence of the hairnet. On 02/21/24 at 12:30 P.M., observation of the tray line during lunch service revealed Dietary Aide (DA) #185 walk into the kitchen and wash her hands. DA #185 did not don a hairnet. DA #185 then walked over to the tray line. The absence of the hairnet was verified by the DON. On 02/21/24 at 1:00 P.M. an interview with the Regional Director of Clinical Services revealed a company had been contacted to consult and clean kitchen. They were on site today. The Regional Director of Clinical Services also verified that hairnets are to be worn in the kitchen. This deficiency represents noncompliance investigated under Complaint Number OH00151189. 365828 Page 5 of 5