Health inspection·January 16, 2025

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure residents and/or resident representatives were able to participate in quarterly care plan conferences for Residents #10 and #62. This affected two residents (#10 and #62) of two resident records reviewed for participation in care planning. The facility census was 99. Findings include: 1. Review of Resident #62's medical record revealed an admission date of 01/30/24. Diagnoses included Alzheimer's disease with late onset, generalized anxiety disorder, major depressive disorder, and fracture of right ulna styloid process. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 00 meaning she was severely cognitively impaired. Resident #62 required partial to moderate assistance with toileting, transfers, and bed mobility, maximal assistance with dressing and personal hygiene. Review of the current care plan revealed Resident #62 was prone to behavior problems including yelling, screaming, and agitation and had a care plan in place which included intervening to protect the rights of others, diverting his attention, and monitoring medications for effectiveness. Review of the progress notes from May 2024 through November 2024 revealed Resident #62 had a care plan meeting 05/06/24 and did not have the next care plan meeting until 11/08/24. Interview on 01/14/25 at 3:25 P.M. with the Social Service Designee (SSD) #513 confirmed Resident #62 did not have a quarterly care plan meeting between 05/06/24 and 11/08/24. 2. Review of Resident #10's medical record revealed an admission date of 05/05/19. Diagnoses included paranoid schizophrenia, unspecified psychosis not due to a substance or known physiological condition, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and major depressive disorder single episode, severe with psychotic features. Review of the annual MDS assessment dated [DATE], revealed Resident #10 had a BIMS score of 15 meaning she was cognitively intact; however, an attempted interview on 01/13/25 at 3:33 P.M. revealed she had impaired thought processes due to paranoid schizophrenia. Resident #10 required partial to moderate assistance with toileting showers, transfers, personal hygiene, lying to sitting, and sitting (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 365800 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365800 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chardon Woods 12340 Bass Lake Road Chardon, OH 44024 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)