Gardens of Euclid Beach

In the surveyor’s words

From the most serious findings on record at Gardens of Euclid Beach, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Sep 23, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF684Sep 23, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF814Sep 23, 2025

  Based 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. Findings include:Observation on 08/18/25 at 9:47 A.M. with Regional Dietary Manager #598 revealed the outside facility dumpster area had three dumpsters with the lids closed. The area surrounding the dumpsters revealed loose debris including incontinence care items, used gloves and various loose trash scattered around on the ground around the dumpsters. Interview at the time of the observation with Regional Dietary Manager #598 confirmed the observation of trash on the ground surrounding the dumpster. […]

• No harm, potential for more than minimal, widespreadF835Sep 23, 2025

  Based 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. Findings include: A review of the facility job description labeled Administrator revealed the purpose of the position was to establish and maintain systems that were effective and efficient to operate the facility in a manner to safely meet the residents' needs in compliance with federal, state, and local requirements. […]

• No harm, potential for more than minimal, widespreadF868Sep 23, 2025

  Based 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. Findings include:A review of the document titled; Euclid Beach QAPI Members that was undated revealed the committee is made up of the following members: Committee Chairperson Administrator Director of Nursing Medical Director Dietary Representative Pharmacy Representative Social Service Representative Activities Representative Environmental Service Representative Infection Control Representative Rehabilitative/Restorative Services Representative Staff Development Representative Safety Representative and Medical Records… […]