Health inspection·May 22, 2019

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure accurate documentation was completed for Resident #8 and Resident #3. This affected two residents (Resident #8 and Resident #3) of 26 residents whose records were reviewed. Findings Include: 1. Record review revealed Resident #8 was admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses including dementia without behavioral disturbance, atrial fibrillation, and high blood pressure. Review of the Medicare 14 day Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed the resident was severely cognitively impaired and had been admitted with two pressure ulcers. Review of Resident #8's skin grid notes dated 05/16/19 revealed the resident had a Stage III (a full thickness wound with full thickness tissue loss. Subcutaneous fat may be visible but bone, tendons, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. The wound may have tunneling or undermining.) pressure ulcer to his sacrum, coccyx or gluteal fold and a Stage III pressure ulcer to the right heel both of which were present upon his initial admission. The site of the wound was the same for each evaluation but the wound nurse, Licensed Practical Nurse (LPN) described the same wound as three different areas. Review of the wound documentation by Certified Nurse Practitioner (CNP) #901 revealed only one progress note dated 05/16/19. The consult note indicated Resident #8 had a Stage III pressure ulcer to the coccyx and another Stage III to the right heel. Interview with the Director of Nursing (DON) on 05/21/19 at 5:15 P.M. revealed the Medical Director's Certified Nurse Practitioner (CNP) #901 made weekly rounds with LPN #900 and together they measured the wounds. The DON confirmed there should not be three different locations for the same wound. The DON said she was working with the staff on their documentation skills. The DON confirmed the facility was not receiving weekly progress notes from CNP #901 regarding wound care and the status of the wounds. 2. Review of Resident #3's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including spastic hemiplegia affecting the left dominant side, disorganized schizophrenia and unspecified dementia with behavioral disturbance. Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #3's restorative program dated 05/07/19 indicated residents who were physically able should walk, even if they were only capable of walking a short distance. Interview on 05/22/19 at 10:30 A.M. with Physical Therapist #805 indicated Resident #3's physical therapy restorative plan included for staff to walk the resident to each meal seven days per week per the resident's tolerance. Review of Resident #3's restorative form dated 05/07/19 to 05/22/19 revealed the resident was on a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366021 If continuation sheet Page 2 of 3 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 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete restorative walk to dine program with ambulation assistance of forty feet with a hemi-walker and stand-by assist. The restorative form did not have documentation the resident received the restorative walk to dine program on 05/07/19 at dinner, 05/08/19 at dinner, 05/09/19 at dinner, 05/10/19 at dinner, 05/11/19 for all meals, 05/12/19 for all meals, 05/16/19 for dinner, 05/17/19 for breakfast and lunch, and 05/18/19 for lunch. Interview on 05/21/19 at 3:30 P.M. with the Director of Nursing (DON) confirmed Resident #3's restorative walk to dine program was completed by facility staff but the staff were not documenting the restorative therapy appropriately. Event ID: Facility ID: 366021 If continuation sheet Page 3 of 3