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. Page 1 of 4 365828 365828 01/08/2025 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observations and measurement of water temperatures on 01/06/25 from 11:29 A.M. to 12:09 P.M. revealed the water temperatures in Resident #4 and #38's room measured 91 degrees Fahrenheit (F). The bottom molding surrounding the air conditioner in Resident #86's room was missing, and there was gap between the air conditioner and the wall where you could see the outside. Resident #86's bed was positioned against that wall approximately a foot below the air conditioning unit. The water temperature in Resident #6's room measured 103 degrees F. The water temperature in Resident #40's room measured 96 degrees F, and the water in Resident #31's room measured 84 degrees F. These observations were verified with the Maintenance Director who stated the water should be at least 112 degrees F. Observation of Resident #58's room on 01/06/25 at 2:00 P.M. revealed there was no hand soap or paper towels next to the sink, the cold water was shut off, and the toilet was dirty and would not flush. Interview during the observation with Resident #58 revealed he had told all the staff about the sink and toilet a month ago. The observations were verified by the Administrator and the Director of Nursing. This deficiency represents non-compliance investigated under Complaint Number OH00161194, OH00161200, and OH00160614. 365828 Page 2 of 4 365828 01/08/2025 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on record review, observations, policy review and interview, the facility failed to serve palatable meals at an appropriate temperature. This affected 11 (Resident #7, #20, #47, #53, #62, #64, #67, #69, #72, #76 and #82) of 96 residents residing in the facility. Residents Affected - Some Findings include: Interviews on 01/02/25 at 8:30 A.M. with Residents #62, #64, #72, and #82 revealed the food was always cold. Resident #72 stated the food was horrible and cold. Observations of tray line on 10/02/24 at 4:20 P.M. noted staff preparing to plate the dinner meals which consisted of ravioli, mixed vegetables, hamburgers, mashed potatoes and bread sticks. Temperatures of the food obtained before plating revealed the regular ravioli was 138 degrees Fahrenheit (F), the mixed vegetables were 158 degrees F, hamburgers were 152 degrees F, puree ravioli was 123 degrees F, and the renal ravioli was 111 degrees F. A test tray was requested and left the kitchen at 4:40 P.M. The test tray arrived on the North one unit at 4:41 P.M. Certified Nursing Assistant (CNA) #202 and Unit Manager #212 immediately began passing the meal trays to the 11 residents residing on the unit. The kitchen had provided one picture of juice which quickly ran out. Unit Manager #212 went to the kitchen to get more juice at 4:46 P.M. and CNA #202 stopped passing trays until Unit Manager #212 returned which was at 4:53 P.M. The last meal tray was delivered at 5:00 P.M. The test tray was completed at 5:01 P.M. with Unit Manager #212. The test tray consisted of regular and pureed ravioli, and mixed vegetables which was what the residents on the unit were served. The regular ravioli measured 82 degrees F. The ravioli tasted luke warm and bland. Unit Manager #212 stated the food was bland and cold. Review of the facility food temperature log noted the minimum holding temperatures for hot food was 135 degrees F. Review of the census provided by the facility revealed Resident #7, #20, #47, #53, #62, #64, #67, #69, #72, #76 and #82 resided on the North one unit. This deficiency represents non-compliance investigated under Complaint Number OH00160614. 365828 Page 3 of 4 365828 01/08/2025 Harvard Gardens Rehabilitation & Care Center 18810 Harvard Ave Cleveland, OH 44122

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and policy review, the facility failed to serve food in a manner to protect it from contamination. This had the potential to affect all residents residing in the facility. The census was 96. Residents Affected - Many Findings include: Observations of tray line on 01/06/25 at 4:33 P.M. revealed two fans running on high speed, one fan was facing the dishwasher, the other was facing the tray line. A layer of brownish/black dust was covering both fans. Interview during the observation with Dietary Manager #210 verified the build of dirt/dust on the fans. Further interview revealed all facility residents consumed food prepared in the kitchen. Review of the undated facility policy titled Nursing Home Kitchen Cleanliness revealed daily tasks included cleaning and sanitizing countertops, stovetops, and food preparation surfaces, washing dishes, utensils, and kitchen equipment, and sweeping and mopping kitchen floors. Weekly tasks involved deep cleaning refrigerators and freezers, cleaning and sanitizing kitchen storage areas, and checking and cleaning vents and exhaust systems. Monthly tasks included conducting a thorough inspection and deep cleaning of the entire kitchen, as well as ensuring pest control measures were in place and functioning. 365828 Page 4 of 4