Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation and interview the facility failed to provide dignified feeding assistance to Resident #15 and
Resident #217. This affected two residents (#15 and #217) of four residents observed for feeding
assistance. The facility identified eight residents (#15, #19, #32, #34, #64, #76, #87, and #217) who
required feeding assistance. The facility census was 113.
Findings include:
1. Review of Resident #15's medical records revealed an admission date of 08/24/22. Diagnoses included
dementia, anorexia and malnutrition.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed no cognition score due to
Resident #15 was rarely understood. Resident #15 required extensive assistance with eating.
Review of the care plan dated 11/03/23 revealed Resident #15 was at risk for nutritional deficits.
Interventions included provide assistance at meals.
Observation was conducted on 11/14/23 at 8:43 A.M. of the breakfast meal for Resident #15. The
observation revealed State Tested Nursing Assistant (STNA) #972 was providing feeding assistance to
Resident #15 in a common dinning area. STNA #972 stood next to Resident #15 while feeding and did not
engage Resident #15 with conversation or eye contact while providing feeding assistance. Interview with
STNA #972 at the time of the observation confirmed she was standing up next to Resident #15 and had not
tried to engage the resident. Resident #15 was not interviewable.
2. Review of Resident #217's medical records revealed an admission date of 10/24/23. Diagnoses included
Alzheimer's and macular eye degeneration.
Review of MDS assessment dated [DATE] revealed no recorded cognition score due to Resident #217 was
rarely understood. Resident #217 required extensive assistance with eating.
Review of the care plan dated 11/08/23 revealed Resident #217 was at risk for nutritional deficits.
Interventions included provide assistance at meals.
Observation was conducted on 11/14/23 at 8:47 A.M. of the breakfast meal for Resident #217. The
observation revealed STNA #973 was providing feeding assistance to Resident #217 in the residents room.
STNA #973 was observed to have been standing up next to Resident #217 and did not engage Resident
#217 with conversation or eye contact while providing feeding assistance. Interview with STNA #973 at
(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 8
Event ID:
366079
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
366079
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza Jennings Home
10603 Detroit Avenue
Cleveland, OH 44102
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)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
time of observation confirmed she standing up next to Resident #217 and had not tried to engage the
resident. Resident #217 was not interviewable.
Review of facility policy titled Feeding of Residents revised 07/28/21 revealed staff should engage with
resident and maintain eye contact and conversation to create a pleasant dining experience.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366079
If continuation sheet
Page 2 of 8
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
366079
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza Jennings Home
10603 Detroit Avenue
Cleveland, OH 44102
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)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, interview, and facility policy review the facility failed to ensure resident's wishes
regarding advanced directives were accurate and clearly identified in a resident's medical record. This
affected one resident (Resident #76) of five residents reviewed for advanced directives. The facility census
was 113.
Findings include:
Review of Resident #76's medical record revealed an admission date of [DATE] and a facility re-entry date
of [DATE] with diagnoses including myositis ossificans traumatica, adult failure to thrive, severe protein
calorie malnutrition, anorexia, dementia, stage three chronic kidney disease, and longstanding persistent
atrial fibrillation.
Review of physician orders for Resident #76 dated [DATE] revealed a Do Not Resuscitate Comfort Care
Arrest (DNR CC-Arrest) order which instructed Do Not intubate Protocol is activated when the patient
experiences cardiac or respiratory arrest and further clarifies all other necessary treatments should be
initiated prior to arrest.
Review of Resident #76's electronic medical record on [DATE] revealed no code status and no advanced
directive paperwork and review of the hard chart revealed no indication of code status or documentation of
advanced directives.
Interview on [DATE] at 10:25 A.M. with Licensed Practical Nurse (LPN) #970 and Central Supply/Medical
Records staff (CSMR) #912 confirmed resident code status and any advanced directive documents could
be found in the front of the hard chart but both LPN #970 and CSMR #912 were unable to find it. CSMR
#912 further confirmed she would be printing and placing a copy of Resident #76's DNRCC-Arrest
paperwork in the hard chart and presented the surveyor with what she referred to as a unit report which
contained resident code statuses and pointed out the nurses can see from this printed report that Resident
#76 was a DNRCC-A. LPN #970 acknowledged she was aware of this form and noted it gets updated
whenever the unit census changes.
Interview on [DATE] at 10:40 A.M. with LPN #971 confirmed she would look at the order summary report for
code status orders and follow accordingly if resident code status was not readily found in the front of the
hard chart or profile in the electronic medical record.
Interview on [DATE] at 03:17 P.M. with State Tested Nurse Aide (STNA) #907 confirmed there was a printed
nursing report on each nursing unit containing important resident information, including resident code
statuses.
Interview on [DATE] at 08:40 A.M. with Medication Technician #893 confirmed if she needed to know a
resident code status, she could find it on the team report sheet, which she pulled out of a drawer on the unit
to show the surveyor the report sheet contained code status orders for each unit resident.
Interview on [DATE] at 09:57 A.M. with STNA #839 confirmed she did not know Resident #76's code status.
When asked how she would find code status, she said to ask one of the nurses.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366079
If continuation sheet
Page 3 of 8
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
366079
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza Jennings Home
10603 Detroit Avenue
Cleveland, OH 44102
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)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Interview on [DATE] at 02:32 P.M. with the Administrator confirmed there was no advanced directive
paperwork in Resident #76's electronic medical record. She further stated there was no DNR paperwork
uploaded to the electronic medical record due to an issue from Resident #76's last hospital admission. The
administrator proceeded to present an order in the medical record date [DATE] indicating Resident #76 was
a full code and added Resident #76 was not a DNRCC-A.
Residents Affected - Few
Interview on [DATE] at 02:50 P.M. with the Director of Nursing (DON) confirmed Resident #76 was a full
code. The DON further confirmed the code status in Resident #76's profile was blank and the order for a full
code was dated [DATE]. The DON also confirmed there was a code status order for a DNRCC-A effective
from [DATE] to [DATE] and no signed advanced directive documentation, adding staff would have
performed cardiopulmonary resuscitation (CPR) even if the order for a DNR was present if they did not
have the signed DNR paperwork because that was the way we do it here.
Review of admission paperwork from re-entry to the facility on [DATE] revealed hospital discharge orders
indicated Resident #76 was a full code.
Review of the undated Advanced Directive Procedure revealed the facility will determine whether the
resident has any advanced directive upon admission, resident wishes will be communicated with facility
staff, and all advanced directive document copies will be obtained and located with the resident's medical
record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366079
If continuation sheet
Page 4 of 8
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
366079
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza Jennings Home
10603 Detroit Avenue
Cleveland, OH 44102
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)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview the facility failed to ensure physician orders were followed for the
use of Prevalon boots. This affected one resident (#7) of two residents observed for Prevalon boots. The
facility census was 113.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #7 revealed she was admitted to the facility on [DATE] with
diagnoses including Alzheimer's disease, dementia, and hypertension.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had a
memory problem, inattention, altered level of consciousness, and was a two-person total dependence for
activities of daily living (ADLs).
Review of the care plan dated 9/21/23 revealed Resident #7 medical conditions required monitoring and
managed as ordered and interventions included to administer medications and treatments as ordered.
Review of the physician orders dated 06/21/22 revealed an order for Prevalon boots every shift.
Observation on 11/13/23 at 10:12 A.M. revealed Resident #7 was in bed with her Prevalon boots located on
the floor near the bathroom entrance.
Observation and interview on 11/16/23 at 8:44 A.M. with Registered Nurse (RN) #814, revealed Resident
#7 was in bed without her Prevalon boots on. Resident #7 had multiple signs posted in her room that
indicated her Prevalon boots were to be put on in the morning. RN #814 verified and confirmed Resident
#7's Prevalon boots were not on and were located on the floor next to a reclining chair.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366079
If continuation sheet
Page 5 of 8
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
366079
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza Jennings Home
10603 Detroit Avenue
Cleveland, OH 44102
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation and interview the facility failed to ensure flammable materials were not left in
resident rooms. This affected one resident (#21) of four residents reviewed for accident hazards. The facility
census was 113.
Review of Resident #21's medical records revealed an admission date of 02/01/19. Diagnoses included
schizoaffective disorder and anxiety.
Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition.
Resident #21 required supervision with transfers, ambulation and personal hygiene.
Review of the care plan dated 09/20/23 revealed Resident #21 was an independent smoker.
Review of smoking assessment dated [DATE] revealed Resident #21 was safe to smoke unsupervised.
Observation on 11/15/23 at 7:53 A.M. revealed Resident #21 had a pack of cigarettes, lighter and a
canister of lighter fluid on his dresser.
Interview on 11/15/23 at 11:29 A.M. with State Tested Nursing Assistant (STNA) #949 confirmed Resident
#21 was an independent smoker and was able to keep his smoking materials in his room. Observation of
Resident #21's room with STNA #949 at time of interview confirmed the canister of light fluid and STNA
#949 stated Resident #21 should not have that substance in his room.
Interview on 11/15/23 at 2:11 P.M. with Administrator revealed Resident #21 should not have had light fluid
in his room and she stated she had educated Resident #21 on not having hazardous material in his room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366079
If continuation sheet
Page 6 of 8
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
366079
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza Jennings Home
10603 Detroit Avenue
Cleveland, OH 44102
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)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation and staff interview the facility failed to maintain a clean, safe, sanitary and
well-maintained environment. This had the potential to affect all residents. The facility census was 113.
Residents Affected - Many
Findings include:
An environmental tour was conducted on 11/16/23 between 10:45 A.M. and 11:20 A.M. with the
Administrator. The following was observed and verified with the Administrator at the time of discovery.
•
Carpeted areas throughout the facility in resident rooms and common areas were noted with stains and
debris throughout.
•
The unit three air purifier had a thick coating of dust and debris covering every part of its filter.
•
The room occupied by Resident #43 was noted with a non-hospital grade power strip with four outlets in
use plugged in to the wall.
•
The poles used to hang intravenous (IV) medication used by Residents #53 and #219 were not clean.
•
The bathroom in Resident #52's room and had noticeable cobwebs on the light fixture about the mirror.
•
The recliner chair in Resident #36's room was dirty and with numerous unknown debris on it.
•
The footboard on the bed used by Resident #220 was detached from one side.
•
The bathroom in Resident #224's room contained an open yellow biohazard bag.
•
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366079
If continuation sheet
Page 7 of 8
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
366079
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza Jennings Home
10603 Detroit Avenue
Cleveland, OH 44102
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)
F 0921
The rooms occupied by Residents #1,#75 and #76 had noticeable water stains on the ceiling.
Level of Harm - Minimal harm
or potential for actual harm
•
The room occupied by Resident #69 had a significant crack in the wall.
Residents Affected - Many
•
The tube feed poles utilized by Residents #25,#69 and #73 were stained with residual tube feed and other
debris.
2. Observation of the laundry area on 11/16/23 at 11:30 A.M. revealed the area behind the washer and
dryer was dirty and full of numerous debris, lint and other items. A pile of towels was noted to be behind the
washer and was discolored brown and full of unknown dirt and debris. Observations of the back panels of
dryers revealed significant lint build up.
Laundry Aide (LA) #897 11/16/23 verified the above findings at the time of observations.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366079
If continuation sheet
Page 8 of 8
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the November 16, 2023 survey of ELIZA JENNINGS HOME?
This was a inspection survey of ELIZA JENNINGS HOME on November 16, 2023. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ELIZA JENNINGS HOME on November 16, 2023?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.