Ohio Living Quaker Heights

In the surveyor’s words

From the most serious findings on record at Ohio Living Quaker Heights, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jul 31, 2026

  Based on record review, staff interview, policy review, Emergency Medical Services (EMS) report, police report, online guidelines from American Heart Association (AHA) and review of staff witness statements, the facility failed to assess a resident for a pulse or vital signs and failed to immediately start Cardio-Pulmonary Resuscitation (CPR) for a resident who was a full code. This resulted in serious life-threatening harm and/or death on [DATE] when Resident #60 was found unresponsive. The facility staff did not check Resident #60 for a pulse and did not obtain vital signs. CPR was not started by facility staff. This affected one (Resident #60) of three residents reviewed for Full Code status and Change of Condition. […]

• Actual harm, isolatedF689Aug 31, 2021

  Based on medical record review, staff interview, review of the local hospital record, review of the manufacturers recommendations, and policy review the facility failed to ensure residents received appropriate supervision during mechanical lift transfers from the bed to the wheelchair. This resulted in Actual Harm when State tested Nursing Assistant (STNA) #39 failed to ensure there were two staff members present for the transfer using the mechanical lift when the lift tipped over resulting in Resident #63 descending from the lift, landing awkwardly onto the bed on his left side, the lift bar hit him in his head and subsequently suffered an abrasion above the right eye and a left femoral neck fracture. […]

• No harm, potential for more than minimal, widespreadF812Nov 8, 2023

  Based on record review, observation and interview, the facility failed to store foods in accordance with professional standards for food service safety. This had the potential to affect 56 residents who received food from the kitchen. The facility census was 56. Findings include: Observation of the Kitchen on 10/31/23 form 8:35 A.M. to 9:05 A.M. revealed the following: 1. In the reach in refrigerator: a. a large bag of lettuce appearing brown and watery dated 10/26/23. b. a bag of hot dogs and ham dated 10/26/23. c. a bag of apparent cheese with no date or label. d. open container whole milk with no date 2. In the milk cooler: a. a four by six inch spillage of milk on the bottom of the cooler with milk cartons stored above. 3. In dry storage and prep area: a. […]

• No harm, potential for more than minimal, patternF578Nov 8, 2023

  Based on record review and interview, the facility failed to have clear documentation of advanced directives in the electronic medical record. This affected four (Residents #9, #10,#13 and #25) of five residents reviewed for advanced directives. The facility census was 56. Findings include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE]. Review of Resident #9's medical records revealed a DNR order form signed by physician on 03/15/21 for an order of Do Not Resuscitate Comfort Care Arrest, (DNR- CCA). There was also a physician order for a code status of Do Not Resuscitate Comfort Care, (DNRCC) dated 08/29/23. 2. Review of the medical record for Resident #10 revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, patternF657Nov 8, 2023

  Based on record review and interview, the facility failed to initiate and update care plans for residents. This affected three (Residents #5, #354 and #48) of 21 residents whose care plans were reviewed The facility census was 56. Findings include: 1. Review of the medical record for Resident #5 revealed an admitted [DATE] and diagnoses including malignant pancreatic cancer, dysphagia, Alzheimer's disease, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had moderately impaired cognition. Resident #5 had an advanced dysphagia diet ordered on 10/10/23 with no new texture change orders since 10/10/23. Review of social service progress notes dated 11/01/23 as late entry of 10/18/23 at 11:56 A.M. […]