Eliza At Chagrin Falls

Based on observation and staff interview, the facility failed to appropriately label and date food for storage. This had the potential to affect 21 of 22 residents who received meals from the facility kitchen. The facility identified one resident (Resident #1) who received no food by mouth. The facility census was 22.Findings include: Observations on 01/20/26 at 9:52 A.M. with Dietary Manager #239 during the initial main kitchen tour revealed the following:In dry storage there was a bag of tortilla chips open to air and not labeled or dated.In the refrigerator there was an almost full pan of orange gelatin left uncovered, unlabeled and undated, a bag of diced carrots left open, unlabeled and undated, and a bag of cheddar cheese left open, unlabeled and undated.In the freezer there was a bag of French fries open to air not labeled and dated and a bag of fried chicken open to air, not labeled or dated.Interview at the time of the observation with Dietary Manager #239 verified the above findings during the initial kitchen tour.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of facility policy, the facility failed to provide showers/bathing per resident preference and schedule. This affected six residents (#10, #11, #14, #25, #34 and #37) out of 22 residents reviewed for showers. The facility census was 22.Findings include:1. Review of the medical record for Resident #25 revealed an admission date of 06/15/24 with diagnoses of metabolic encephalopathy, acute cystitis (bladder infection), dementia, heart failure, anxiety disorder, delirium, and malignant neoplasm of trachea. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive decline. The resident required moderate assistance for all activities of daily living (ADL) including grooming, hygiene, and toileting needs. Resident #25 was dependent on staff for all mobility and transfer needs and utilized a wheelchair. The resident was always incontinent of bowel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of Centers for Medicare & Medicaid Services memorandum and review of facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were in place or implemented when indicated and the facility failed to ensure the catheter valve/port on Resident #33's indwelling catheter (a flexible tube used to drain urine from the bladder) drainage bag (a bag that collects urine) was not on the floor. This affected four Residents (#1, #14, #33, #36) out of ten residents reviewed for EBP and/or catheter use. This had the potential to affect 14 residents (#1, #6, #10, #12, #14, #19, #21, #22, #25, #27, #28, #33, #34 and #36) identified with EBP and seven residents (#6, #10, #14, #19, #22, #25 and #33) identified by the facility with urinary catheters. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 01/14/26 and his diagnoses included aftercare following surgery of genitourinary system, acute cystitis and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and review of facility policy, the facility failed to appropriately cover an indwelling urinary catheter drainage bag with a dignity/privacy pouch. This affected one resident (#33) out of three residents reviewed for urinary catheters and had the potential to affect seven residents (#6, #10, #14, #19, #22, #25 and #33) identified by the facility with urinary catheters. The facility census was 22.Findings include: Review of the medical record for Resident #33 revealed an admission date of 01/19/26 and his diagnoses included benign prostatic hyperplasia (enlargement of the prostate causing urinary issues) with lower urinary tract symptoms, chronic kidney disease, and diabetes. Review of January 2026 physician orders revealed Resident #33 had an order for an indwelling urinary catheter and catheter care was to be provided every shift. Observation on 01/20/26 at 9:16 A.M. revealed Resident #33 was lying in a bed with his indwelling urinary catheter drainage bag on the side of his bed with part of the bag laying on the floor. From the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to ensure residents were free of significant medication errors. This affected two residents (#1 and #25) out of five residents reviewed for medication administration. The facility census was 22.Findings include:1. Review of the medical record for Resident #25 revealed an admission date of 06/15/24 with diagnoses of metabolic encephalopathy, acute cystitis (bladder infection), dementia, heart failure, anxiety disorder, delirium, and malignant neoplasm of trachea. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive decline. Resident #25 required moderate assistance for all activities of daily living including grooming, hygiene, and toileting needs, and was dependent on staff for mobility and transfers utilizing a wheelchair. Review of the care plan dated 12/26/25 revealed Resident #25 had congestive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to ensure all medications were stored appropriately in medication carts. This had the potential to affect all 11 residents residing in the facility. Findings include: Observation of the medication carts completed on 05/30/23 at 9:15 A.M. revealed there were a total of 23 loose medications observed. There were 13 loose medications observed in the Cherry Hill medication cart, as well as 10 loose medications and a yellow powder spilled throughout the top drawer of the Maple Lane medication cart. The facility had a total of two medication carts. Interview on 05/30/23 at 9:30 A.M. with Registered Nurse (RN) #801 revealed she confirmed there were 13 loose medications observed in the Cherry Hill medication cart, as well as 10 loose medications and a yellow powder spilled throughout the top drawer of the Maple Lane medication cart.

Based on observation and interview, the facility failed to maintain the overhead hood vents, fire suppression nozzles, and backsplash behind the stove in a clean, sanitary, and safe manner. This had the potential to affect ten of the eleven residents residing in the facility. Resident #76 did not receive food from the facility kitchen. The facility census was 11. Findings include: A tour of the kitchen on 05/30/23 from 9:15 A.M. through 9:44 A.M. with Dietary Manager #821 revealed the overhead vents and the fire suppression nozzles were greasy and had accumulated dust. The backsplash behind the stovetop was greasy. Dietary Manager #821 verified the condition of the hood, nozzles, and back splash at the time of the observation.

Based on record review and interview, the facility failed to complete a comprehensive assessment for Resident #275 within 14 days after admission. This finding affected one resident (#275) of ten residents reviewed for comprehensive assessments. The facility census was 11. Findings include: Review of the medical record for Resident #275 revealed an admission date of 05/16/23. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of bilateral middle cerebral arteries, celiac disease, Parkinson's disease, and chronic heart failure. Review of Resident #276's Minimum Data Set (MDS) 3.0 assessments revealed an admission assessment was initiated with an assessment reference date (ARD) of 05/19/23 but was not completed as required. Interview with Registered Nurse (RN) #796 on 05/31/23 at 12:50 P.M. confirmed the admission MDS assessment for Resident #275 was opened on 05/19/23 but sections C, D, E, and Q were still in progress, and the assessment was not completed on time. Interview with Licensed Social Worker (LSW) #802 on 05/31/23 at 1:10 P.M. confirmed she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for Resident #7 to include anticoagulant use. This affected one resident (#7) of five residents who were reviewed for care plans with high-risk medications. The facility census was 11. Findings include: Review of the medical record for Resident #7 revealed an admission date of 05/10/23. Diagnoses included acute on chronic systolic congestive heart failure, atrial fibrillation, essential primary hypertension, and ischemic cardiomyopathy. Review of the admission Minimum Data Set (MDS) assessment, dated 05/17/23, revealed Resident #7 had intact cognition. Resident #7 received an anticoagulant seven of the seven days prior to the assessment reference date. Review of Resident #7's physician orders effective May 2023 revealed Eliquis 5 milligrams (mg) twice daily for blood thinner (anticoagulant). Review of Resident #7's comprehensive care plan dated 05/24/23 revealed a focus of activities of daily living, risk for falls, alteration in nutrition status, risk for pain, and risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the fall care plan for Resident #76 was updated in a timely and complete manner. This affected one resident (#76) of ten resident care plans reviewed. The facility census was 11. Finding include: Resident #76 was admitted to the facility on [DATE] with diagnoses including intracerebral hemorrhage, gastrostomy status, and abnormal findings on diagnostic imaging of central nervous system. Review of the admission Minimum Data Set (MDS) assessment, dated 05/15/23, revealed Resident #76 had severely impaired cognition. The resident could sometimes make self understood and sometimes understood others. Resident #76 was totally dependent on two people for transfers. The resident was totally dependent on one person for locomotion and eating. The resident required the extensive assistance of two people for bed mobility, dressing, toilet use, and personal hygiene. The Morse Fall scale reviews completed on 05/10/23, 05/16/23, 05/18/23, 05/21/23, 05/22/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and policy review, the facility failed to appropriately store medications in two of two medication carts, and in one of one medication room refrigerator. This had the potential to affect all 19 residents residing in the facility. Findings include: Observation on 04/27/21 at 11:08 A.M. with Registered Nurse (RN) #250 during medication administration from the medication cart labeled cherry revealed a vial of Lispro U-100 insulin stored in the top drawer of the medication cart. The Lispro insulin vial was opened, not dated, not labeled, and was not in a labeled storage box or container. Interview with RN #250 at the time of the observation confirmed the above finding. Observation on 04/27/21 at 11:26 A.M. with RN #251 of medication storage room revealed three Aplisol 5 tuberculin units per 0.1 milliliter vials (used to diagnose tuberculosis) stored in the refrigerator. Each of the three Aplisol vials were opened and undated. Interview with RN #251 at the time of the observation confirmed the above finding. Observation on 04/27/21 at 11:44…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review the facility failed to ensure transmission based precautions were initiated upon admission for Resident #70, the facility failed to ensure staff and visitors followed appropriate transmission based precautions guidelines for Resident #70, and the facility failed to ensure soiled laundry was handled appropriately for Resident #119. This affected two Residents (#70 and #119) of three residents reviewed for infection control, and had the potential to affect all 19 residents residing in the facility. Findings include: 1. Record review revealed Resident #70 was admitted on [DATE] from the hospital with diagnoses including sicca syndrome (Sjogren syndrome) (an autoimmune disease), orthostatic hypotension, essential primary hypertension, and repeated falls. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition, required limited one staff assistance for bed mobility and toileting, limited two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to ensure oxygen tubing was dated per acceptable standards of nursing practice for Residents #119 and #123, and the facility did not ensure oxygen administration orders were in place for Resident #123. This affected two Residents (#119 and #123) of two residents reviewed for respiratory care. The facility reported two residents on oxygen therapy. The facility census was 19. Findings include: 1. Record review revealed Resident #119 was admitted on [DATE] with diagnoses of sepsis, urinary tract infection, chronic obstructive pulmonary disease (COPD) and congestive heart failure. Review of physician's orders dated 04/23/21 revealed continuous oxygen via nasal cannula at two liters per minute (LPM), and check oxygen saturation and respiratory rate every shift. Observation on 04/26/21 at 1:27 P.M. revealed Resident #119 sitting up in a wheelchair with oxygen nasal cannula in place, oxygen setting at two LPM, and the oxygen tubing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.