Health inspection·January 8, 2025

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 record review, observation and interviews, the facility failed to ensure a well maintained and comfortable environment. This affected seven (Residents #4, #6, #31, #38, #40, #58, and #86) of 29 residents residing on the second floor. Findings include: Review of the medical record for Resident #4 revealed an admission date of 05/30/24. Diagnoses included vascular dementia with behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/15/24, revealed Resident #4 had intact cognition and was independent with activities of daily living (ADL). Review of the medical record for Resident #6 revealed an admission date of 06/16/23. Diagnoses included bipolar disorder, psychotic disorder with delusions, and schizophrenia. Review of the quarterly MDS assessment, dated 11/03/24, revealed Resident #6 had intact cognition and required maximum assistance with ADLs. Review of the medical record for Resident #31 revealed an admission date of 11/15/24. Diagnoses included schizophrenia, unspecified and obesity. Review of the quarterly MDS assessment, dated 12/10/24, revealed Resident #31 had intact cognition and was independent with ADLs. Review of the medical record for Resident #38 revealed an admission date of 12/04/20. Diagnoses included adult failure to thrive and Alzheimer's disease. Review of the quarterly MDS assessment, dated 10/14/24, revealed Resident #38 had impaired cognition and was independent with ADLs. Review of the medical record for Resident #40 revealed an admission date of 10/28/21. Diagnoses included schizophrenia and anxiety disorder. Review of the quarterly MDS assessment, dated 10/04/24, revealed Resident #40 had impaired cognition and was independent with ADLs. Review of the medical record for Resident #58 revealed an admission date of 10/19/23. Diagnoses included anxiety disorder, dementia with behavioral disturbances. Review of the quarterly MDS assessment, dated 11/03/24, revealed Resident #58 had intact cognition and was independent with ADLs. Review of the medical record for Resident #86 revealed an admission date of 03/25/24. Diagnoses included alcohol dependence, uncomplicated, vascular dementia, moderate with agitation, and personality disorder. Review of the quarterly MDS assessment, dated 11/18/24, revealed Resident #86 had impaired cognition and required maximum assistance with ADLs. (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 4 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 01/08/2025 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)