Health inspection·January 4, 2020

F 0679 12/23/19. Level of Harm - Minimal harm or potential for actual harm Review of the December 2019 activities progress notes revealed Resident #14 had an additional one on one visit on 12/14/19 at 3:44 P.M. Residents Affected - Few Interview on 01/03/20 at 4:45 P.M. with Activities Director (AD) #337 revealed Resident #14 was pretty much non-responsive but used to get up in wheelchair until he didn't tolerate being up. AD #337 stated Resident #14 would moan and groan while up so then he required one on one visits three times weekly. AD #337 confirmed Resident #337 wasn't receiving these one on one activity visits three times a week. AD #337 stated that the documentation indicating Resident #14 participated in Busy Hands was not correct. AD #337 stated Busy Hands involved things like folding cloth items and doing things with their hands, which was not appropriate or possible for Resident #14 due to his contractures. AD #337 stated when she asked her staff what they were doing for Resident #14 in relation to the Busy Hands they weren't able to provide a clear reason why they documented Busy Hands as an activity or what they did with Resident #14. Review of the facility policy titled, Individual Programming, revised 10/11/11, revealed recreation services will provide one on one individual programming at least three times weekly to all guests who are unable to attend group activities. The purpose was to ensure all guests who are unable to participate in group programs have consistent, goal-oriented and therapeutic, individualized recreation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366274 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 366274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Chagrin Falls 150 Cleveland Street Chagrin Falls, OH 44022 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** 3. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnosis including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side if the body) following cerebral infarction (stroke), anxiety disorder and nicotine dependence. The quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #18 required limited assistance for transfers, walking, locomotion and dressing. The brief interview mental status (BIMS) score of 15 indicated he/she had no cognitive deficits. A care plan relative to smoking, dated 05/19/19 and last reviewed 09/20/19, revealed Resident #18 had been assessed as being safe to smoke independently. Due to diminished reflexes the resident agreed to continue with the use of a smoking apron. The past two Smoking Evaluations, done 08/29/19 and 12/19/19, were incomplete. The evaluations were left blank regarding whether Resident #18 was a supervised or unsupervised smoker and if they were a safe smoker or an unsafe smoker. Interview on 01/04/20 at 8:47 A.M. with Assistant Director of Nursing #302 verified Resident #18's Smoking Evaluations, 08/29/19 and 12/19/19, were not complete and did not determine the level of supervision needed for smoking. Based on observation, record review and interview the facility failed to ensure fall prevention interventions were consistently implemented as planned for Residents #19 and #47 and the facility failed to ensure smoking assessments, including level of staff supervision were completed for Resident #18. This affected two of four residents reviewed for falls and one of one resident reviewed for smoking. The facility census was 41. Findings include: 1. Medical record review for Resident #19 revealed an admit date of 11/09/18 with diagnoses that included history of falling, Alzheimer's disease, diabetes and heart disease. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had impaired cognition and required extensive assistance from staff for mobility and transfers. Resident #19 had a history of falls and was frequently incontinent of bowel and bladder. Resident #19's care plan initiated on 05/31/19 indicated he/she was at risk for falls due to impaired cognition and muscle weakness. Interventions included to have one side of the bed against wall with a matt to floor while the resident was in bed and to have bolsters applied to the bed. The January 2020 physicians' order revealed two fall prevention orders. Resident #19 was to have bolster wedges, used for positioning, applied to the sides of the bed. The second order was a matt to the floor when resident is in bed. Observation on 01/04/20 at 9:03 A.M. revealed Resident #19 was alone in the room lying in bed and the floor matt was standing up against the wall. At 9:05 A.M. State Tested Nursing Assistant (STNA) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366274 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 366274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Chagrin Falls 150 Cleveland Street Chagrin Falls, OH 44022 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 #304 walked into the room and placed the matt on the floor next to the bed. The STNA then stated Resident #19 just finished breakfast and verified the matt should be on floor next to the bed and walked out of the room. Observation and interview on 01/04/20 11:03 A.M. with the Assistant Director of Nursing (ADON) revealed Resident #19 was lying in bed without the bolster wedges applied to the bed. The ADON verified the observation and stated Resident #19 should have bolsters wedges applied to the bed. Review of the facility policy titled, Fall Management, revised 10/2019 revealed the facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls. 2. Record review of Resident #47 revealed an admission date of 12/07/19. Diagnoses included displaced fracture of left arm, osteoarthritis, and history of falling. The admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had intact cognition, required supervision of one staff for bed mobility, transfers, and toilet use, and had a fall with a fracture in the six months prior. Review of the January 2020 physician orders revealed an active order dated 12/29/19 for a floor matt to the floor by the bed due to falls. Review of the care plan initiated on 12/07/19 revealed Resident #47 was at risk for fall related injury and falls related to muscle weakness, deconditioning, gait and balance problems, decreased use of left arm, history of falls, and bladder incontinence. Interventions revised on 12/29/19 include a floor mat to be placed on the open side of bed. Review of the nursing note dated 12/29/19 at 5:30 A.M. revealed Resident #47 was found on the floor in sitting position next to bed. Resident #47 reported she fell out of bed and reported slight pain on the right side of neck and left shoulder. Resident #47 had a fracture of the left arm prior to admission to facility. Resident #47 moved her right upper arm without deficits and the left upper arm was already immobilized in sling due to the previous fracture. Resident #47's vital signs were assessed, gait belt applied, and she was lifted into bed with two staff. Resident #47 reported both knees hurt, but no open areas or bruising was observed to the knees. Resident #47 was able to stand with minimal assist once helped off floor. The on call physician was notified. Resident #47 was alert and oriented. Review of the Interdisciplinary Team (IDT) meeting note dated 12/30/19 at 12:08 P.M. revealed facility staff discussed the fall on 12/27/19 when Resident #47 was observed sitting on floor next to bed. The fall interventions were for staff to encourage Resident #47 to wear proper footwear, have the call light within reach, and provide activities to minimize falls. The new fall intervention was for a floor mat to the floor on the open side of her bed. Interview on 01/02/20 at 11:12 A.M. with Resident #47 revealed she fell out of the bed one night and wasn't sure what happened. Resident #47 stated she did not have an injury form this fall. At this time, the floor matt was observed leaning against the dresser and was not on the floor next to her bed. Observation on 01/02/20 at 11:15 A.M. with Licensed Practical Nurse (LPN) #336 verified the floor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366274 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 366274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Chagrin Falls 150 Cleveland Street Chagrin Falls, OH 44022 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 matt was not on floor near Resident #47's bed. LPN #336 verified Resident #47 had a physician order for a floor matt to the floor next to her bed since 12/29/19. Observations on 01/02/20 at 5:23 P.M., 01/03/20 at 2:40 P.M., and 01/04/20 at 7:37 A.M. revealed Resident #47 in bed and the floor matt was observed in the room but not next to the bed. Residents Affected - Few Observation on 01/04/20 at 7:42 A.M. with STNA #305 confirmed the floor matt was not in place and began to place the floor mat on the floor next to Resident #47's bed. STNA #305 verified Resident #47 had one fall where she slid out of bed. Review of the facility policy titled, Fall Management, revised 10/2019 revealed the facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366274 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 366274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Chagrin Falls 150 Cleveland Street Chagrin Falls, OH 44022 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to serve the correct portion sizes to meet the needs of residents receiving pureed diets. This affected four (Residents #2, #25, #27, and #36) of four residents who received pureed diets. Findings include: Review of the menu for the dinner meal on 01/03/20 revealed beef vegetable stew, biscuit, and tossed salad with dressing was being served. Review of the diet spreadsheet for 01/03/20 revealed the pureed diet was to receive two #10 scoops for the beef vegetable stew (which would equal 6 ounces) and one #10 scoop of pureed vegetable of the day (which would equal 3 ounces). Interview on 01/03/20 at 4:36 P.M. with Dietary Staff (DS) #338 after observing tray line food temperatures revealed she had already plated and placed the pureed food in the cooler since there were only four residents that received pureed diet at dinner. DS #338 stated she would reheat them and take a temperature when they were ready to be served. DS #338 stated she used the gray handled scoop for the pureed beef stew and the green handled scoop for the pureed vegetable which was the zucchini. At this time, review of the diet spreadsheet with DS #338 confirmed she had used the incorrect portion sizes for the pureed meals. DS #330 stated she only provided one scoop servings for beef stew using the grey handled scoop. Review of the Portion Control Chart located in the kitchen revealed the green handled scoop was the #12 scoop and provided a 2 2/3 ounce serving. The gray handled scoop was the #8 scoop and provided a 4 ounce serving. The off white or cream-colored handle scoop was the #10 scoop and provided a 3 ounce serving. DS #338 provided pureed residents with only three ounces of vegetable beef stew and 2 2/3 ounces of the vegetable, which was less than directed on the diet spreadsheet. Observation on 01/03/20 at 4:39 P.M. DS #338 pulled the four pre-plated pureed meals from the reach-in cooler. Observation of the four pre-plated pureed revealed pureed beef stew, pureed zucchini, and mashed potatoes. At this time DS #338 stated she was going to redo the pureed meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366274 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 366274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Chagrin Falls 150 Cleveland Street Chagrin Falls, OH 44022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to properly store, prepare and maintain food in a clean and sanitary manner in the main kitchen and one nursing unit refrigerator. This had the potential to affect all residents except three residents (Residents #14, #16, and #30) who received nothing by mouth. The facility census was 41. Findings include: 1. Tour of the main kitchen on 01/02/20 from 8:38 A.M. to 9:07 A.M. with Dietary Staff (DS) #339 revealed the electric stove had dried grease stains on the surface, backsplash, and down the front of the stove. The fryer located between the stove and the steamer, had various grease stains and food debris. The table that held the fryer sat on a moderate amount of grease spillage and food debris. The side of the steamer next to the fryer had various grease splatter that appeared from the fryer. The steam table shelf underneath had various dried spills and what appeared to be dried grease stains along the front of the steam table underneath the lip of the steam table top surface. The floor next to the stove had a whitish dried spill with various debris. Under the three compartment sink there was an electric panel box with the lid off sitting on the floor with various food and debris surrounding it. The wall behind the dirty side of the dish machine moderated amount of brownish stains and a blackish stain that appeared to be mold. The utensil holder by the tray line belt had a moderate amount of dried brownish stains. All findings were verified by DS #339 during the observation/tour of the kitchen. 2. Observation on 01/02/20 at 10:02 A.M. of the nursing one unit refrigerator with DS #339 revealed a foul odor when the refrigerator was opened. There was a gray plastic bag with plate of food that was not dated or labeled. There was also a small container of food covered with foil that was not labeled or dated. The refrigerator had various food splatters. The above findings were verified by DS #339. Interview on 01/02/20 at approximately 10:05 A.M. with Licensed Practical Nurse (LPN) #340 revealed the nursing one unit refrigerator was used for all residents. Review of the facility policy titled Operation and Cleaning Procedures dated April 2010 revealed the policy was to promote safety and infection control, all employees shall follow standard operations and cleaning procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366274 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 366274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Chagrin Falls 150 Cleveland Street Chagrin Falls, OH 44022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to complete a risk assessment or implement infection control measures for Legionella. This had the potential to affect all 41 residents in the facility. Residents Affected - Many Findings include: Review of the facility's Legionellosis/Legionnaires Disease/Legionella and Other Water-Borne Pathogens Prevention Policy, dated 09/17, revealed the facility had a generic policy for Legionella. The facility had not completed a Legionella or water-borne pathogens risk assessment and they had no monitoring or control measures in place for Legionella prevention. Interview with the Administrator on 01/04/20 at 2:50 P.M. verified a Legionella risk assessment had not been completed and they had no monitoring or control measures in place for Legionella prevention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366274 If continuation sheet Page 8 of 8