Gardens of Euclid Beach

Inspectors wroteBased on closed record review, review of emergency medical services (EMS) run report, staff interview, and facility policy review, the facility failed to initiate Cardiopulmonary Resuscitation or timely call EMS for Resident #13, a resident with advance directives for a Full Code status (indication for healthcare providers to perform all possible lift-saving measures in the event of a cardiac or respiratory arrest). This resulted in Immediate Jeopardy and Actual Harm/Subsequent Death on [DATE] at 5:40 P.M. when Resident #13 was found unresponsive and Licensed Practical Nurse (LPN) #521 failed to initiate CPR. EMS was not called until [DATE] at 6:23 P.M. and arrived at the facility at 6:32 P.M. Upon arrival, EMS determined Resident #13 was deceased , CPR was not in progress by facility staff and EMS were informed Resident #13 had been pronounced deceased in the facility at 5:40 P.M. [...]

Inspectors wroteBased on observation, closed record review, review of emergency medical services (EMS) run reports, review of the facility assessment and floor plan, review of facility staffing, policy review and interview, the facility failed to accurately assess and provide timely and necessary medical intervention for residents identified to have an acute change in condition. In addition, the facility failed to provide basic life support (BLS) and Cardiopulmonary Resuscitation (CPR) in accordance with BLS/CPR standards of practice, failed to maintain adequate staffing resources to allow for efficient and effective emergency response to residents' with cardiopulmonary arrest, and failed to have effective systems in place for staff to obtain timely assistance during a CPR code. This resulted in Immediate Jeopardy and Actual Harm/Subsequent Death for Resident #13, #58 and #74. [...]

Inspectors wroteBased on observation, pest control invoice reviews, staff interview and facility policy review, the facility failed to dispose of garbage in a clean and sanitary manner. This had the potential to affect all 53 residents residing in the facility.

Inspectors wroteBased on observation, record review, job description review, and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This had the potential to affect all residents residing in the facility. The facility census was 53.

Inspectors wroteBased on document review and interview the facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) committee consisted of the required members. This had the potential to affect all residents residing in the facility. The facility census was 53.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure a clean and sanitary homelike environment was provided for residents. This had the potential to affect all residents residing in the facility. The facility census was 53.

Inspectors wroteBased on personnel file record review, interview, and facility policy review, the facility failed to ensure a complete orientation, including applicable training and facility-specific policies, was provided to newly hired Certified Nursing Assistants (CNAs) and licensed nurses. This had the potential to affect all residents residing in the facility. The facility census was 53.

Inspectors wroteBased on record review, staff and resident interviews, observation, and review of the facility policy, the facility failed to ensure Resident #3, #29, #45, #49, #53, #63, #41, #7, #44, #1, #2, and #5 were provided assistance with activities of daily living for showering. This affected 12 residents (#3, #29, #45, #49, #53, #63, #41, #7, #44, #1, #2, and #5) of 22 resident records reviewed for activities of daily living. The facility identified 44 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #16, #18, #19, #20, #21, #22, #23, #25, #27, #29, #30, #32, #36, #39, #40, #41, #42, #43, #44, #45, #47, #49, #50, #51, #52, #53, #54, #55, #61, #62, and #63) who required staff assistance for showers and bathing. The facility census was 53.

Inspectors wroteBased on interview, observation, record review, and facility assessment review, the facility failed to maintain sufficient levels of competent staff to ensure residents received the care needed to maintain the highest quality of life. This affected two residents (#58 and #74) and had the potential to affect six additional residents (#22, #26, #31, #35, #46, and #61) who resided on the first floor unit of the facility. The facility census was 53.

Inspectors wroteBased on observation, staff interview and review of the facility policy, the facility failed to ensure medications in the medication cart were labeled and stored in proper containers. This had the potential to affect 30 Residents (#2, #6, #8, #16, #18, #19, #20, #21, #22, #23, #25, #26, #30, #31, #33, #35, #36, #37, #39, #42, #43, #44, #45, #46, #47, #49, #50, #52, #60, and #61) who received medications from the medication carts reviewed. The facility census was 53.

Inspectors wroteBased on observation, interviews, record review and review of facility policy, the facility failed to ensure the policy pertaining to use and storage of food in resident room refrigerators was implemented and addressed temperature monitoring for food safety. This affected four residents (Residents #4, # 9, #43, and #44) of four residents reviewed for personal food storage. The facility identified seven residents (Residents #4, #9, #16, #36, #43, #44 and #47) as storing food in room refrigerators. The facility census was 53.

Inspectors wroteBased on document review and interview, the facility failed to have an updated and accurate facility assessment to indicate sufficient staffing for the first floor. This had the potential to affect six residents (#22, #26, #31, #35, #46 and #61) identified by the facility as residing on the first floor The facility census was 53.

Inspectors wroteBased on medical record review, interview and facility policy review, the facility failed to ensure medical record documentation included weekly skin assessments as ordered and care planned for Resident #1, #3, #7, #9, #29, #44, #45, #49, #53, #63, and #69, and failed to ensure the change of condition and subsequent death of Resident #76 was documented in the medical record. This affected 12 Residents (#1, #3, #7, #9, #29, #44, #45, #49, #53, #63, #69 and #76) of 22 residents reviewed for complete resident records. The facility census was 53.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a catheter drainage bag was placed in a privacy bag to maintain dignity. This affected one resident (Resident #27) of three residents (Residents #4, #5 and #27) identified with urinary drainage systems. The Facility census was 53.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure the physician was notified of resident changes in condition. This affected two residents (#13 and #85) of 22 residents reviewed for change in condition. The facility census was 53.

Inspectors wroteBased on record review, interview and review of facility policy, the facility did not ensure Resident #55's care plan was revised to include physician ordered oxygen therapy. This affected one resident (#55) of 22 residents reviewed for care plans. The facility identified three residents (#5, #39 and #55) who required oxygen therapy. The facility census was 53.

Inspectors wroteBased on record review, observation and interviews, the facility failed to ensure Resident #29 was provided corrective lens and vision care appointments per physician orders. This affected one resident (Resident #29) of one resident reviewed for vision services. The facility census was 53.

Inspectors wroteBased on observation, record review, clinical nursing assistant orientation program staff sign off review, interview and facility policy review, the facility failed to ensure appropriate supervision was provided for residents requiring supervision while smoking and failed to ensure residents did not have smoking items in their personal possession. This affected two residents (Resident #45 and #49) of three residents reviewed for smoking. The facility identified 26 residents (Residents #4, #5, #6, #7, #12, #13, #14, #15, #17, #18, #22, #26, #40, #41, #43, #44, #45, #49, #50, #51, #52, #53, #54, #60, #61, and #63) who smoked. The facility census was 53.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure oxygen tubing was dated as changed weekly for equipment management and infection control. This affected two residents (Resident #39 and Resident #55) of three residents (Residents #5, #39 and #55) identified by the facility as utilizing oxygen. The facility census was 53.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure monthly pharmacy reviews were completed for two residents (Residents #4 and #53) of five reviewed for unnecessary medications. The facility census was 53.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician ordered labs were completed timely as required. This affected one resident (Resident #53) of 22 residents reviewed for physician orders. The facility census was 53.

Inspectors wroteBased on record review and interview, the facility failed to ensure annual performance evaluations were completed for all state tested nursing assistants (STNA's). This had the potential to affect all 55 residents residing in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure nurse staffing information was posted. This had the potential to affect all 55 residents residing in the facility.

Inspectors wroteBased on observation, staff interviews, facility policy review and review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of COVID-19, the facility failed to maintain proper infection control procedures to prevent the spread of infection. This affected one resident (#21) and had the potential to affect fifteen residents (#5, #9, #17, #18, #19, #22, #23, #26, #29, #32, #33, #35, #40, #42, #44) who resided on the Sycamore Unit (rooms 202 through 213). The facility census was 57.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure medications were stored in a secure manner and medications where labeled with residents' names and date opened. This affected three residents (#48, #15 and #51) and had the potential to affect all 58 residents in the facility who received medications from medication carts 1, 2, 3 and 4.

Inspectors wroteBased on observation and interview the facility failed to maintain a safe and sanitary environment for residents. This affected five residents (#10, #16, #21, #54 and #164) of 58 residents residing in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement safe and responsible smoking practices and policies. This affected one resident (#48) of one resident reviewed for smoking and had the potential to affect all 58 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #48 was treated with respect and dignity. This affected one resident (#48) of one resident reviewed for resident rights. The facility census was 58.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #48 was screened for services and placement in the nursing facility. The facility also failed to notify the appropriate State agency (the Ohio Department of Mental Health) when two residents (#4 and #48) with a level two mental illness had a significant change in condition. This affected two residents (#4 and #48) of two residents reviewed for Pre-admission Screen and Resident Review (PASARR). The facility census was 58.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #48 received timely assistance with applying for Social Security benefits from social service staff. This affected one resident (#48) of one resident reviewed for resident rights. The facility census was 58.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the State Ombudsman was notified of resident transfers to the hospital. This affected three residents (#4, #19 and #164) and had the potential to affect all 58 residents residing in the facility.

Inspectors wroteBased on staff interview, review of personnel files and the abuse policy and procedure, the facility failed to develop and implement policies and procedures to include screening of all employees against the State of Ohio Nurse Aide Registry to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property and failed to obtain reference checks. This affected six employee files (Licensed Practical Nurse (LPN) #103, LPN #301, Director of Admissions #54, Housekeeping Assistant #82, Human Resource Director (HRD) #100 and the Administrator) of eleven personnel files reviewed for screening against the State of Ohio Nurse Aide Registry and four employee files (LPN #301, State Tested Nurse Aide (STNA) #35, STNA #151 and Floor Technician #83) of eleven personnel files reviewed for reference checks. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staff washed their hands between handling soiled floor mats and clean steam table pans. This had the potential to affect 105 residents out of a census of 112. Residents #27, #47, #61, #65, #69, #86 and #106 did not receive receive meals from the kitchen.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the medical director was an active participant of the Quality Assurance (QA) Committee. This had the potential to affect all residents. The facility census was 112.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure appropriate hand washing was performed during care of a resident on isolation precautions, personal protective equipment was properly disposed of, proper signage was posted regarding the need for isolation precautions, and biohazardous waste was properly disposed of. This affected one (Resident #43) of one resident reviewed for isolation precautions and had the potential to affect all 112 residents currently residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive assessment was coded correctly for Resident #48 for vision, Resident #34 for medications, Resident #115 for discharge location, Resident #12 for refusal of care and Resident #5 for life expectancy. This effected five of 35 Residents (#5, #8, #12, #14, #16, #23, #26, #27, #34, #37, #43, #48, #51, #57, #58, #61, #64, #66, #75, #78, #79, #82, #92, #97, #99, #103, #104, #107, #108, #109, #111, #113, #115, #163 and #313) reviewed for assessment accuracy. The facility census was 112.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the envionment was manintained in a clean manner and in good repair for all residents. This affected 27 (Residents #9, #10, #11, #12, #22, #34, #35, #55, #56, #57, #58, #61, #62, #65, #68, #69, #80, #86, #87, #93, #96, #97, #98, #99, #112, #163 and #365) of 112 residents currently residing in the facility.

Inspectors wroteBased on resident interview, record review and staff interviews, the facility failed to ensure Resident #107 had care plan meetings as required. This affected one (Resident #107) of two residents reviewed for care plan meetings. The facility census was 112.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure accurate advanced directive information was present throughout the medical record for Resident #12. This affected one of one resident (Resident #12) reviewed for advanced directives. The facility census was 112.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) form was given to Resident #73 upon the discontinuation of skilled services. This affected one (Resident #73) of three residents reviewed for proper notices of non-coverage. The facility census was 112. Findings Include: Review of the medical record for Resident #73 revealed Resident #73 was given a Notice of Medicare Non-Coverage (NOMNC) on 09/26/18 indicating skilled services was would be discontinued on 09/28/19. Review of census records revealed Resident #73 remained in the facility. Further review of the medical record revealed Resident #73 did not receive a SNF ABN as required. Interview with Social Worker #89 on 10/08/19 at 10:55 A.M. verified the lack of notice. [...]

Inspectors wroteBased on interview, record review and physician notes, the facility failed to ensure a care plan was initiated for a resident admitted with a chronic cough. This affected one resident (Resident #64) of 35 residents whose care plans were reviewed. The facility census was 112.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents care plans were updated to meet the residents needs. This affected one resident (Resident #43) of 35 residents whose care plans were reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and accurate discharge for Resident #313 . This affected one resident (Resident #313) of two residents reviewed for the discharge process.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure there was intervention for prevention of functional decline in abilities for Resident #48, who declined in bed mobility, transfers, eating and toileting. This affected one of six (Resident's #5, #48, #75, #99, #109, and #163) reviewed for activities of daily living. The facility census was 112.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #75) received nail care of five Residents (#16, #75, #99, #109, and #163) reviewed for activities of daily living (ADL). The facility census was 112.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident #48 was provided with glasses after a vision exam indicated she required them. This effected one of one resident reviewed for vision.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident #78's right hand splint was applied correctly. This effected one of one resident reviewed for positioning. The facility census was 112.

Inspectors wroteBased on interview and review of personnel files, the facility failed to ensure performance reviews were completed every 12 months and failed to ensure State Tested Nurse Aides (STNA) completed 12 hours of in-service education every twelve months. This affected two (STNA #131 and #166) of five STNA personnel files reviewed.

Inspectors wroteBased on record review and interview, the facility failed to ensure a residents was discharged with the correct medication. This affected one resident (Resident #313) of three residents reviewed for discharge. The facility census was 112.

Inspectors wroteBased on record review, review monthly pharmacy recommendations and interview, the facility failed to ensure a gradual dose reduction was attempted for Resident #108. This affected one resident (Resident #108) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and staff interview, the facility failed to have three years of state survey results, including complaint investigations, readily accessible to residents and the general public. This had the potential to affect all 112 residents.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure posted nursing staff information was updated in a timely manner. This had the potential to affect all residents. The facility census was 112.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the facility assessment contained all required information. This had the potential to affect all residents. The facility census was 112. Findings Include: Review of the facility assessment revealed the following: • All of the documentation in the assessment was on the previous owners letter head. • The census information contained in the assessment was out of date (from October 2018). • Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies were noted to be for the previous owners of the facility, and no updated contracts were noted. Interview with the Administrator on 10/6/19 at 10:45 A.M. verified the above findings.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure monthly physician's orders were signed and dated as required. This affected three (Residents #14, #111 and #114) of twenty eight residents reviewed. The facility census was 112.