Health inspection·March 6, 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 observation, interview, record review, and facility policy review the facility failed to ensure fall interventions were in place for Resident #47. This affected one resident (#47) of three residents reviewed for falls. The facility census was 50. Findings Include: Review of Resident #47's medical record revealed an admission date of 06/07/23 and diagnoses including acute pulmonary edema, bipolar disorder, generalized anxiety disorder, hypertension, depression, dementia with other behavioral disturbance, and moderate protein calorie malnutrition. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 was cognitively impaired and did not reject care. Resident #47 required substantial/partial assistance to sit to stand. Resident #47 could wheel 50 feet in her wheelchair with two turns with supervision or touching assistance. Resident #47 had two falls coded since the prior assessment. Review of a fall risk evaluation dated 02/27/24 revealed Resident #47 had one to two falls in the past three months and had intermittent confusion. The assessment indicated a score of 10 or higher meant the resident was at a high risk for falls; Resident #47 had a score of 11 thus was at risk for falls. Review of the plan of care dated 06/08/23 and revised 02/13/24 revealed Resident #47 was at higher risk for falls due to gait and balance problems due to osteoarthritis of the knee and psychoactive drug use as well as being unaware of safety needs. Interventions listed included Dycem (non-slip material) to wheelchair for safety (dated 06/21/23) and place call before you fall signage in plain view in room (dated 07/12/23). Observation on 03/06/24 starting at 8:03 A.M. of Resident #47 revealed she was dressed and seated in her wheelchair by the nurses' station. Registered Nurse (RN) #116 and RN #103 were asked if Resident #47 had Dycem on her wheelchair as it could not be visualized on the wheelchair while Resident #47 was seated. RN #103 assisted Resident #47 to stand, and no Dycem was noted on her wheelchair. RN #103 then reviewed Resident #47's current care plan for falls with the surveyor and verified the Dycem was not in place per Resident #47's plan of care. During this time RN #103 was questioned regarding the call before you fall signage intervention also listed on Resident #47's plan of care. At 8:08 A.M. RN #103 accompanied the surveyor to Resident #47's room and no sign was visualized. RN #103 verified the lack of signage at the time of observation. (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: 366021 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 03/06/2024 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)