Inspection Reports for Shaker Gardens Assisted Living
3550 NORTHFIELD ROAD, SHAKER HEIGHTS, OH, 44122
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
48 residents
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Census: 48
Deficiencies: 1
Date: Oct 17, 2024
Visit Reason
The inspection was conducted to evaluate the facility's medication administration practices and ensure medication error rates were not 5 percent or greater.
Findings
The facility failed to ensure a medication error rate of five percent or less, with five medication errors out of 27 observed opportunities, resulting in an 18.5% error rate affecting two of three residents reviewed. Specific errors included incorrect dosages and failure to follow pharmacy instructions during medication administration.
Deficiencies (1)
Failed to ensure medication error rate of five percent or less, with five medication errors out of 27 observed opportunities.
Report Facts
Medication errors: 5
Observed opportunities for error: 27
Medication error rate: 18.5
Census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #118 | Named in medication administration errors and interviews confirming findings |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: Mar 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation under Complaint Number OH00151229 to assess the facility's compliance with fall prevention interventions for Resident #47.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00151229 and is an example of continued non-compliance from the complaint survey dated 02/13/24.
Findings
The facility failed to ensure fall interventions were in place for Resident #47, including the absence of Dycem (non-slip material) on the wheelchair and lack of 'call before you fall' signage in the resident's room. The Director of Nursing confirmed no physician's order for Dycem was found, indicating non-compliance with the resident's care plan.
Deficiencies (1)
Failure to ensure fall interventions were in place for Resident #47, including lack of Dycem on wheelchair and absence of fall signage.
Report Facts
Residents affected: 1
Residents reviewed for falls: 3
Facility census: 50
Fall risk score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #116 | Assisted Resident #47 to stand and was questioned about fall interventions | |
| Registered Nurse (RN) #103 | Verified lack of Dycem and signage per Resident #47's care plan during observation | |
| Director of Nursing (DON) | Interviewed regarding physician's orders and fall interventions for Resident #47 |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Feb 13, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure Resident #49 did not leave the facility without staff knowledge and did not ensure a safe discharge.
Complaint Details
This deficiency represents noncompliance investigated under Complaint Number OH00151042.
Findings
The facility failed to prevent Resident #49 from leaving without staff knowledge or medications, despite awareness of the resident's intent to leave. The facility did not conduct an investigation or notify law enforcement as required by policy. The resident left against medical advice and the facility lacked interventions for an unplanned discharge.
Deficiencies (1)
Failed to ensure Resident #49 did not leave the facility without staff knowledge and did not ensure a safe discharge.
Report Facts
Facility census: 48
Residents reviewed for elopement: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #200 | Licensed Practical Nurse | Confirmed second floor was not a secured unit and Resident #49 was ambulatory and not an elopement risk |
| Registered Nurse #203 | Registered Nurse | Reported searching for Resident #49 and notifying the Director of Nursing |
| Director of Nursing | Director of Nursing | Notified about missing resident, confirmed no investigation or law enforcement notification, and lack of interventions for unplanned discharge |
| Licensed Practical Nurse #204 | Licensed Practical Nurse | Assigned to Resident #49 on 02/10/24 and last saw him in common area |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 11
Date: May 2, 2022
Visit Reason
The inspection was conducted based on complaints regarding multiple issues including resident notification of account balances, advance directives documentation, discharge procedures, care planning, nutritional concerns, infection control, and immunization compliance.
Complaint Details
This inspection substantiates Complaint Number OH00132084 related to discharge procedures, infection control, and other resident care concerns.
Findings
The facility failed to notify Medicaid residents about account balances exceeding limits, lacked signed advance directives in medical records, discharged a resident without proper notification or consent, failed to develop adequate care plans for residents' needs, did not obtain weights as ordered, served incorrect food portion sizes, failed to maintain dumpster areas, did not properly implement infection control procedures including PPE use and TB testing, and failed to ensure required influenza and pneumonia vaccinations.
Deficiencies (11)
Failed to notify Medicaid residents when account balances exceeded SSI resource limits.
Failed to ensure residents' signed advance directive forms were in medical records.
Discharged a resident without adequate reason, documentation, or notification to resident or representative.
Failed to provide timely notification to resident and representative before discharge.
Failed to prepare resident for safe transfer or discharge.
Failed to develop individualized care plans for residents' risk of skin breakdown and refusal of contracture prevention devices and nail care.
Failed to obtain weights as ordered by physician for nutritional assessment and treatment.
Failed to ensure serving sizes for vegetables and mechanical soft diet were served according to the menu.
Failed to maintain dumpsters and surrounding areas free from trash and debris.
Failed to implement infection control procedures for PPE including proper mask use and face shield disinfection; failed to complete required two-step TB testing for residents.
Failed to ensure influenza and pneumonia vaccinations were completed or documented as required.
Report Facts
Residents affected: 5
Residents affected: 2
Residents affected: 1
Residents affected: 2
Facility census: 42
Weight measurements missed: 4
Serving size: 4
Serving size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #616 | Licensed Practical Nurse | Reported resident refusal of orthotics and nail care issues; involved in discharge and care planning for Resident #38 and Resident #9 |
| LPN #620 | Licensed Practical Nurse | Observed resident refusal of orthotics and verified nail care concerns for Resident #9; Infection Control Preventionist |
| SW #572 | Social Worker | Involved in discharge planning and care conferences for Resident #38 |
| DON | Director of Nursing | Managed discharge referrals and provided statements regarding Resident #38 discharge and infection control |
| STNA #603 | State Tested Nurse Aide | Assisted with packing belongings and observed resident behavior during discharge of Resident #38 |
| STNA #597 | State Tested Nurse Aide | Observed infection control breaches related to PPE use during meal delivery |
| ICP #620 | Infection Control Preventionist | Provided information on infection control policies and TB testing compliance |
| Dietitian #635 | Dietitian | Verified missing weights and nutritional care concerns for Resident #24 |
| LPN #631 | Licensed Practical Nurse | Observed with mask pulled down exposing mouth and nose |
Inspection Report
Routine
Deficiencies: 3
Date: May 22, 2019
Visit Reason
The inspection was conducted to assess compliance with medication administration accuracy and proper documentation of resident medical records and restorative therapy in the nursing facility.
Findings
The facility failed to maintain a medication error rate below 5%, with two medication errors out of 30 opportunities affecting one resident. Additionally, the facility did not ensure accurate wound documentation for one resident and incomplete documentation of restorative therapy for another resident, despite the therapy being provided.
Deficiencies (3)
Failed to maintain medication error rate below 5%, with two medication errors in 30 medication administration opportunities affecting one resident.
Failed to ensure accurate documentation of wound care for Resident #8, with inconsistent wound site descriptions and lack of weekly progress notes from Certified Nurse Practitioner.
Failed to maintain accurate documentation of restorative therapy for Resident #3, with missing documentation for multiple dates despite therapy being completed.
Report Facts
Medication administration opportunities: 30
Medication errors: 2
Medication error rate: 6.66
Residents observed for medication administration: 6
Residents affected by medication errors: 1
Residents whose records were reviewed: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #806 | Licensed Practical Nurse | Involved in medication administration error for Resident #38 |
| Certified Nurse Practitioner #901 | Certified Nurse Practitioner | Responsible for wound care documentation and weekly rounds |
| Director of Nursing | Director of Nursing | Interviewed regarding wound care documentation and restorative therapy documentation |
| Licensed Practical Nurse #900 | Licensed Practical Nurse | Assisted Certified Nurse Practitioner with wound measurements |
| Physical Therapist #805 | Physical Therapist | Provided information on Resident #3's restorative therapy plan |
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