Gardens of North Olmsted

Inspectors wroteBased on observation, resident and staff interviews, and review of daily staff schedules, staff time punch detail, daily posted nurse staffing, the Facility Assessment (FA), and the Payroll Based Journal (PBJ) report, the facility failed to have sufficient staffing. This affected one resident (Resident #10) reviewed for incontinence care, five residents (Residents #2, #29, #52, #67 and #78) who voiced staffing concerns, and had the potential to affect all 78 residents residing in the facility.

Inspectors wroteBased on review of staff schedules, staff time punch detail and interview, the facility failed to ensure the Director of Nursing (DON) worked full-time as the DON and did not work as a staff nurse when the census was over 60. This had the potential to affect all 78 residents residing in the facility.

Inspectors wroteBased on observation, interview, and review of facility dietary menus, the facility failed to ensure meals were served at a palatable temperature. This affected three residents (Residents #11, #29 and #67) and had the potential to affect all other residents who received meals from the kitchen. The facility indicated one resident (Resident #2) who received nothing by mouth. The facility census was 78.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to maintain a clean and sanitary kitchen and failed to ensure resident room refrigerators were monitored and maintained as required. This had the potential to affect all residents receiving meals from the kitchen, and affected three residents (Residents #18, #29 and #35) of three residents reviewed for room refrigerators. The facility indicated one resident (Resident #2) who received nothing by mouth. The facility census was 78.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to maintain a safe environment by permitting smoking materials (lighters, tobacco paraphernalia and vapes) in resident rooms which violated facility policy and safe smoking protocols. This affected five residents (Residents #6, #31, #60, #73 and #74) of six residents reviewed for smoking. The facility census was 78.

Inspectors wroteBased on observation, interview and record review, the facility failed to respect and honor a resident's choice to not have care provided by Certified Nursing Assistant (CNA) #588. This affected one resident (Resident #39) of three residents reviewed for respect and dignity. The facility census was 78.

Inspectors wroteBased on record review, interviews, and review of the facility policy, the facility failed to complete a Self-Reported Incident (SRI) when an allegation of verbal abuse was reported involving Certified Nursing Assistant (CNA) #588 cursing at Resident #39. This affected one resident (Resident #39) of three residents reviewed for abuse. The facility census was 78.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to initiate an abuse investigation for an allegation of verbal abuse and take action to prevent further mistreatment by the alleged perpetrator (CNA #588) pending the outcome of the investigation. This affected one resident (Resident #39) of three residents reviewed for abuse. The facility census was 78.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to provide timely incontinence care for Resident #10 who was dependent on staff for toileting hygiene and incontinence of bowel resulting in being left in a soiled incontinence brief, having dried stool on the skin for extended periods, and prolonged exposure to stool odors. This affected one resident (Resident #10) of three residents reviewed for incontinence care. The facility census was 78.

Inspectors wroteBased on observation, interview, and review of the medical record and facility policy, the facility failed to ensure dental concerns were addressed timely. The affected one resident (Resident #7) of one resident reviewed for dental care. The facility census was 78.

Inspectors wroteBased on observation, interview, and review of facility menu and policy, the facility failed to ensure a physician ordered therapeutic diet was followed. This affected one resident (Resident #13) of one resident reviewed for therapeutic diets. This had the potential to affect 48 residents (Residents #3, #4, #6, #7, #10, #11, #12, #13, #14, #17, #18, #19, #24, #26, #27, #28, #29, #33, #34, #36, #37, #39, #42, #44, #45, #47, #48, #49, #50, #52, #54, #56, #59, #62, #64, #65, #66, #67, #68, #69, #70, #71, #72, #74, #75, #76, #78 and #79) who received a therapeutic diet. The facility census was 78.

Inspectors wroteBased on observation, interview, and review of the medical record and facility policy, the facility failed to adequately prepare food to address a resident's pain and chewing difficulties. This affected one resident (Resident #7) of one resident reviewed for chewing difficulties. The facility census was 78.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure staff obtained proper Cardiopulmonary Recusation (CPR) certification for healthcare providers. This had the potential affect 59 Residents (#1, #2, #3, #4, #9, #11, #13, #14, #15, #16, #17,#19, #20, #21, #22, #23, #28, #30, #31, #33 ,#34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #48, #50,#52, #53, #56, #57, #59, #61, #62, #63, #64, #65, #69, #70, #73, #74, #75, #76, #77, #81, #83, #84, #86, #88, #89, and #91) who had elected for an advance directive of full code status . The facility census was 91.

Inspectors wroteBased on closed record review, interview, review of emergency medical services (EMS) run report, review of the facility's timeline and investigation, and facility policy review, the facility failed to ensure a resident's change in condition was timely addressed. This affected one resident (#34) of three residents reviewed for changes in condition. The facility census was 91.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure pain medications were available for administration. This affected one resident (#58) of three residents reviewed for medications. The facility census was 91.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure medical records were accurate and complete. This affected two Residents (#3 and #58) of three residents reviewed for documentation. The facility census was 91.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure food portions were appropriate and food served was palatable. This affected all residents with the exception of Resident #50, who did not consume meals from the kitchen. The facility census was 75.

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to ensure the building was in good repair and free of trash buildup. This had the potential to affect all 75 residents in the facility.

Inspectors wroteBased on record reviews, observations, interviews and facility policy review, the facility failed to ensure fall assessments were completed, falls were documented in the medical record, fall prevention interventions were in place, and fall investigations were thorough. This affected four (Residents #18, #22, #52 and #76) of five residents reviewed for falls. The facility census was 75.

Inspectors wroteBased on record reviews, observations, interviews and review of manufacturer instructions, the failed to ensure Resident #22's stoma supplies were available timely and failed to ensure Resident #75 had a working television. This affected two (Residents #65 and #75) of four residents reviewed accommodation of needs. The facility census was 75.

Inspectors wroteBased on record review, review of the missing items log, observation, interviews and facility policy review, the facility failed to report and allegation of misappropriation for Resident #22 to the State agency. This affected one (Resident #22) of three residents reviewed for misappropriation. The facility census was 75.

Inspectors wroteBased on record review, review of the missing items log, observation, interviews and facility policy review, the facility failed to thoroughly investigate missing items for Resident #22. This affected one Resident #22) of three residents reviewed for misappropriation. The facility census was 75.

Inspectors wroteBased on record review, observation, interview and review of the facility policy, the facility failed to ensure Resident #33's care conference was scheduled during the required timeframe. This affected one (Resident #33) of three residents reviewed for care conferences and had the potential to affect 10 additional residents (Resident's #6, #11, #14, #16, #23, #30, #33, #41, #45, #58, #75) identified by the facility as needing to have a care plan scheduled. The facility census was 75.

Inspectors wroteBased on record review, observation, interview and review of the facility policy, the facility failed to ensure Resident's #41, #58 and #73 were provided with appropriate care and services. This affected three residents (Resident's #41, #58 and #73) out of four residents reviewed for activities of daily living (ADL) care for dependent residents. The facility census was 75.

Inspectors wroteBased on record review, review of hospice records, interview and facility policy review, the facility failed to ensure changes in conditions were properly addressed for Residents #76 and #77. This affected two (Residents #76 and #77) of three residents reviewed for change in condition. The facility census was 75.

Inspectors wroteBased on observation, interview and record review, the facility failed to timely identify and treat urinary tract infections for Resident's #22 and #33. This affected two residents (#22 and #33) out of three residents reviewed for urinary tract infections. The facility census was 75.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to transport Resident #63 to dialysis appointments as ordered. This affected one resident (#63) out of one resident reviewed for dialysis. The facility census was 75.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #22 was provided appropriate dental services. This affected one (Resident #22) of three residents reviewed for dental services. The facility census was 75.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a resident elopement was reported to the State Agency as required. This affected one resident (Resident #129) of three residents reviewed for elopement. The facility census was 76.

Inspectors wroteBased on review of the medical record, staff and resident interviews, review of the in-progress facility investigation, review of a local police report, review of local weather reports, and facility policy review, the facility failed to prevent an elopement for one resident (Resident #129) of three residents reviewed for elopement. The facility census was 76.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure complete medical records were maintained for one resident (Resident #129) of three records reviewed for accurate and complete medical records. The facility census was 76.

Inspectors wroteBased on interviews, record review and observations the facility failed to ensure the courtyard was maintained in a clean and safe manner. This had the potential to affect all 72 residents in the facility. Findings Include: Interview on 06/10/25 at 8:27 A.M. with Resident #36 revealed she has been outside one time since she admitted to the facility. Interview on 06/10/25 at 8:59 A.M. with Certified Nursing Assistant (CNA) #300 revealed residents are sometimes taken outside to the courtyard. Interview on 06/11/25 at 1:33 P.M. with CNA #301 revealed they do take residents outside when it is nice outside and that she took some of the residents outside the weekend before. Interview on 06/11/12 at 1:47 P.M. with Resident #68 revealed has not seen anyone go to the courtyard and she goes outside with smokers to socialize and go outside, even though she does not smoke. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #35, Resident #36 and Resident #60 were comprehensively assessed for their preference for activities and did not ensure sufficient activities were in place to meet their needs. This affected three residents (Resident #35, Resident #36, and Resident #60) out of four residents reviewed for activities. Findings Include: 1. Resident #35 was admitted on [DATE] with diagnosis of alcoholic cirrhosis of liver, Alzheimer's disease, unspecified mood disorder, dementia, major depressive disorder, anxiety disorder, wandering diseases, impulse disorder, dementia severe with agitation, cellulitis of right lower limb, hyperlipidemia, gastro-esophageal reflux disease, essential hypertension, and alcohol abuse in remission. [...]

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure the staff covered their hair exposed while working with or around food in the kitchen area. This had the potential to affect all 75 residents residing at the facility who receive food from the kitchen.

Inspectors wroteBased on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure residents' living environment including resident rooms, dining room, and smoking area were kept clean and homelike. This had the potential to affect all 75 residents residing in the facility.

Inspectors wroteBased on record review, family and staff interview, and review of facility policy, the facility failed to ensure a resident met the criteria to be admitted to and reside on the secured unit This affected one (Resident #77) of three residents reviewed for abuse. The facility census was 75.

Inspectors wroteBased on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure the residents who were dependent on staff for activities of daily living received assistance with showers and personal hygiene. This affected two (Resident #24 and #70) of three residents reviewed for activities of daily living. The facility census was 75.

Inspectors wroteBased on observation, review of the resident council meeting minutes, and interviews the facility failed to ensure the residents' environment was clean, sanitary, and was in good repair. This affected 53 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #13, #14, #15, #17, #18, #20, #21, #22, #23,#25, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #45, #46, #47, #48, #49, #52, #53, #54, #55, #56, #57, #58, #60, #61, #62, #64) of 65 residents reviewed for a homelike environment. The facility census was 65.

Inspectors wroteBased on record review and interview, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This had the potential to affect all 60 residents. The facility census was 60.

Inspectors wroteBased on record review and staff interview the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure that nurse aides were evaluated annually. This had the potential to affect all 60 residents who resided in the facility. The facility census was 60.

Inspectors wroteBased on personnel record review and staff interview, the facility failed to provide documented evidence of dementia training for all staff. The facility had a secure unit. This had the potential to affect all 60 residents that resided in the facility. Findings Include: Review of personnel record for State Tested Nurse Aide (STNA) #114 revealed a hire date of 11/08/22 with no documentation of dementia training. Review of personnel record for STNA #136 revealed a hire date of 05/25/22 with no documentation of dementia training. Review of personnel record for STNA #165 revealed a hire date of 06/22/22 with no documentation of dementia training. Review of personnel record for STNA #827 revealed a hire date of 10/29/19 with no documentation of dementia training. Review of personnel record for STNA #828 revealed a hire date of 07/15/20 with no documentation of dementia training. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to provide housekeeping services to ensure the resident environment, including bathrooms were maintained in a clean and sanitary manner. This affected 18 residents (#1, #9, #10, #15, #16, #17, #19, #27, #31, #33, #34, #38, #40, #42, #45, #46, #49, and #52) of 60 residents residing in the facility. Findings Included: Initial tour on 12/04/22 from 7:30 A.M. to 8:40 A.M. revealed concerns regarding the cleanliness and upkeep of the facility. Interviews were conducted with seven residents (Resident #10, Resident #17, Resident #19, Resident #31, Resident #40, Resident #46, and Resident #49) from 8:30 A.M. to 6:00 P.M. on 12/04/22, 12/05/22 and 12/06/22. All seven residents voiced concerns about the cleanliness of the environment. The interviews revealed that housekeeping rarely come into rooms and clean. [...]

Inspectors wroteBased on observation, interview, taste test and policy review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected four residents (#11, #12, #15 and #35) of four residents who were prescribed pureed diets. The facility census was 60.

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to ensure discharge planning was completed for one resident (Resident #25) out of two residents (#25 and #61) reviewed for discharge planning. The facility census was 60.

Inspectors wroteBased on closed record review, facility policy and procedure review and interview, the facility failed to ensure a comprehensive discharge summary was completed for Resident #61 as required. This affected one resident (#61) of two residents (Residents #25 and #61) reviewed for discharge planning. The facility census was 60.

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure weekly weights were done per physician's orders. This affected two residents (Resident #17, and Resident #40) of five residents reviewed for nutrition. The facility census was 60.

Inspectors wroteBased on observation and interview, the facility failed to insure medications were properly stored. This affected three residents (#12, #21 and #49) of three residents review for medications not properly stored. The facility census was 60. Findings Included: An initial tour of this facility on 12/04/22 from 8:30 A.M. to 9:15 A.M. revealed loose pills were observed on the floor in two different rooms, the room for Resident #12 and Resident #21 and the room for Resident #49. Upon entrance into Resident #12 and Resident #21 room at 8:40 A.M. a small round white pill was observed laying on the floor close to the entrance of the bathroom. Interview with Licensed Practical Nurse (LPN) #177 on 12/04/22 verified the pill was in the room on the floor which she stated 'looked like Remeron. LPN #177 returned back to the room after looking up the pill and stated it was Remeron. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a dignified dining experience for all residents. This affected 13 (Residents #3, #7, #16, #18, #36, #48, #56, #62, #72, #75, #81, #91 and #92) of 86 residents that received meals prepared in the facility kitchen. The facility census was 88, Residents #21 and #90 received nothing by mouth.

Inspectors wroteBased on observation and interview the facility failed to ensure outdated insulin vials were disposed of. This affected four (Resident #64, Resident #50, Resident #6, and Resident #11) of 11 residents residing on the Grand Heritage Unit who were reviewed for insulin use. The facility census was 88.

Inspectors wroteBased on observation, interview and policy review the facility failed to ensure equipment and food preparation areas were maintained in a clean and sanitary manner, and foods were dated when opened and properly stored and labeled. This had the potential to affect 86 of 88 residents whose meals were prepared in the kitchen. Residents #21 and #90 received nothing by mouth.

Inspectors wroteBased on observation and staff interview the facility failed to maintain a clean and sanitary environment. This affected 20 residents (Residents #1, #8, #13, #15, #17, #23, #24, #31, #35, #40, #42, #51, #54, #55, #63, #65, #66, #67, #84 and #193) currently residing on the Arcadia Unit and Residents #6, #11, #14, #22, #26, #29, #38, #60, #70 and #92. The facility census was 88.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide water flushes as ordered by the physician for Resident #90 and failed to ensure call lights were within reach for Resident #25 and Resident #85. This affected one (Resident #90) of two residents reviewed for tube feeding administration and two (Residents #25 and #85) of two residents reviewed for call lights. The facility census was 88. 1. Review of the medical record for Resident #90 revealed he was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), protein-calorie malnutrition and presence of a gastrostomy tube (tube into the stomach). Review of the physician order for Resident #90, dated 09/03/19, revealed Resident #90 was to receive water flushes at 40 milliliters per hour (ml/hr). Observation on 09/25/19 at 04:16 P.M. [...]

Inspectors wroteBased on record review, and interview, the facility failed to ensure catheter care was provided every shift. This affected two (Resident #16 and Resident #68) of eight residents reviewed for catheter care. The facility census was 88.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure consistent use of adaptive equipment for two (Resident #22 and #43) of ten residents reviewed for adaptive equipment. The facility census was 88.

Inspectors wroteBased on observation, interview, record review, and review of facility policy the facility failed to ensure proper hand hygiene and wound cleansing was implemented during Resident #85's dressing change. This affected one (Resident #85) of seven residents reviewed for wound care. The facility census was 88.

Inspectors wroteBased on observation, interview and policy review the facility failed to ensure the smoking policy was adhered to for Resident #22. This affected one (Resident #22) of eight residents (#11, #22, #29, #36, #62, #69, #77 and #85) reviewed for smoking.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure refuse was properly disposed of. This had the potential to affect all 86 residents currently residing in the facility.

Inspectors wroteBased on record review and staff interview the facility failed to ensure monthly physician orders were signed and dated as required. This affected four (Residents #2, #77, #78 and #87) of 26 residents whose physician's orders were reviewed. The facility census was 88.