Inspection·February 6, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 02/06/25 at 11:39 A.M. with SSD #866 revealed the missed November care conference was discovered after an audit was performed which prompted SSD #866 to schedule and complete a care conference 01/16/25. Review of the Care Planning Conference Policy revised 06/24/21 revealed Interdisciplinary Care Conferences will be held for the following reasons: Admission, Annually, Quarterly, Significant change, discharge as needed, and as needed. Event ID: Facility ID: 366274 If continuation sheet Page 2 of 9 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 02/06/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 Resident #11's pressure ulcer wound care was completed as ordered. This affected one (Resident #11) of one resident reviewed for pressure ulcer wounds. Residents Affected - Few Findings include: Review of Resident #11's medical record revealed the resident was admitted [DATE] with diagnoses including senile degeneration of the brain, essential hypertension and major depressive disorder. Review of Resident #11's care plans revealed an intervention dated 10/29/24 for treatments to skin impairments as ordered. Review of Resident #11's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #11's physician orders revealed an order dated 01/10/25 to cleanse the left heel wound with normal saline, pat dry, apply betadine to the wound and cover with an abdominal (ABD) pad and Kerlix every night shift for wound care. Review of Resident #11's physician orders revealed an order dated 01/23/25 to cleanse the right lateral ankle and right lateral foot wound with normal saline, pat dry, apply betadine and cover with an ABD pad and Kerlix every night shift and as needed. Review of Resident #11's Skin and Wound Evaluation form dated 01/30/25 revealed the resident had an Unstageable left heel pressure wound (full- thickness tissue loss where the depth cannot be assessed due to the presence of necrotic tissue such as hard black or brown eschar tissue) which measured 2.3 centimeters (cm) length by 2.1 cm depth. Review of Resident #11's Skin and Wound Evaluation form dated 01/30/25 revealed the resident had a right ankle deep tissue injury (DTI) or pressure induced damage to underlying tissue pressure wound which measured 1.5 cm length by 1.3 cm width. The pressure wound bed had eschar (tan, brown or black dead tissue that sheds or falls off from the skin). Review of Resident #11's Skin and Wound Evaluation form dated 01/30/25 revealed the resident had a Stage three (full thickness skin loss) right middle heel pressure ulcer which measured 3.7 cm length by 4.1 cm depth. Review of Resident #11's physician orders revealed an order dated 01/30/25 to cleanse the right heel wound with normal saline, pat dry, apply betadine moistened 2 x 2 gauze and cover with an ABD and Kerlix every nightshift for wound care. Review of Resident #11's Skin and Wound Evaluation form dated 01/30/25 revealed the resident had a right lateral forefoot DTI pressure wound which measured 1.0 cm length by 1.6 cm width. Observation on 02/05/25 at 3:16 P.M. to 3:32 P.M. with Registered Nurse (RN) Wound Nurse #816 of Resident #11's pressure ulcer wound care revealed RN Wound Nurse #816 setup her field with the wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366274 If continuation sheet Page 3 of 9 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 02/06/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care dressings on the resident's overbed table, washed her hands and put on gloves, used scissors to cut through the previous dressings to the left foot and then the right foot, used normal saline to remove the previous dressing to the left foot which was partially stuck to the heel and then used normal saline to remove the dressing to the right foot and right lateral ankle which was partially stuck to the heel, removed her gloves and washed her hands, put on new gloves, placed a 2 x 2 dressing with iodine to the left heel, covered with an ABD pad and wrapped with Kerlix, placed a 2 x 2 dressing with iodine on the right heel, right lateral foot and ankle wounds, covered with an ABD pad and wrapped with Kerlix. The nurse placed tape on the Kerlix to both the right and left feet with the date and time written on the tape, placed the dressing packages in the trash, removed her gloves and washed her hands. Regional RN #872 assisted RN Wound Nurse #816 with Resident #11's pressure ulcer wound care. Interview on 02/05/25 at 3:51 P.M. with Regional RN #872 confirmed RN Wound Nurse #816 did not clean Resident #11's bilateral heels with normal saline and pat dry prior to placing the 2 x 2 dressings with iodine on the resident's bilateral heels as ordered. Review of the Clean Dressing Change policy dated 09/18/23 revealed to check the physician order for the correct treatment, establish a clean field, perform hand hygiene, remove the old dressing and discard, remove gloves, perform hand hygiene, apply clean gloves, cleanse the wound site gently with the solution ordered, apply any medication as ordered, dress the wound site, discard soiled materials, remove gloves and wash the hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366274 If continuation sheet Page 4 of 9 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 02/06/2025 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 0692 Provide enough food/fluids to maintain a resident's health. 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 Resident #3's nutritional supplement was implemented as planned. This affected one (Resident #3) of two residents reviewed for nutrition. Residents Affected - Few Findings include: Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease, hypertensive heart disease with heart failure and mild cognitive impairment. Review of Resident #3's physician orders revealed an order dated 10/03/24 for a regular diet, regular texture, thin consistency. Review of Resident #3's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited cognitive impairment. Review of Resident #3's dietary progress note dated 12/31/24 at 11:48 A.M. revealed the resident was slightly underweight and the regular diet remained tolerated. The resident had between meal supplements in place for nutrition support and snacks were noted in the resident's room. Review of Resident #3's lunch meal ticket dated 02/05/25 revealed the resident's standing orders were ice cream and four fluid ounces of water. Observation on 02/05/25 at 12:45 P.M. revealed Resident #3 was provided turkey, stuffing, green bean casserole, pumpkin pie, a roll and grape juice. Resident #3 was not provided the ice cream as ordered for the resident's weight loss. Interview on 02/05/25 at 12:55 P.M. with Nutrition Associate #870 indicated she was unsure why Resident #3 did not have the ice cream on his tray when it was on the meal ticket. Review of the menus and spreadsheets revealed the lunch meal consisted of three ounces of roasted savory turkey, four ounces of savory stuffing, four ounces of green bean casserole, one dinner roll and a slice of pumpkin pie. Review of the Nutritional Supplementation policy revised 10/05/24 revealed it was the policy of the facility to provide nutritional supplements when clinically necessary to maintain weight, health and hydration of residents. Supplements would be considered a last resort measure after substitutes, food alternatives, and liberalizing the diet had been attempted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366274 If continuation sheet Page 5 of 9 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 02/06/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure Resident #36's expired insulin was discarded as appropriate. This affected one (Resident #36) of five residents observed for medication administration. Findings include: Observation on [DATE] at 12:15 P.M. with Licensed Practical Nurse (LPN) #822 revealed LPN #822 completed blood glucose testing for Resident #36 with a result of 175. LPN #822 then administered three units of Humalog fast acting insulin into the resident's right arm using a Humalog Kwikpen. The date first used written on the Kwikpen in marker was [DATE]. Interview on [DATE] at 12:20 P.M. with LPN #822 confirmed Resident #36's Humalog Kwikpen was expired and should have been discarded after 28 days after first being used. The Humalog Kwikpen expired [DATE]. Review of the Insulin Lispro (Humalog) KwikPen Instructions for Use form revised [DATE] revealed an in-use pen should be stored at room temperature up to 86 degrees Fahrenheit and away from heat and light. The pen should be thrown away after 28 days, even if the pen still had insulin left in the pen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366274 If continuation sheet Page 6 of 9 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 02/06/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the blood glucose testing (BGT) machine/glucometer was appropriately cleaned and disinfected to prevent the potential cross-contamination of blood borne pathogens affecting one resident (Resident #36) with the potential to affect an additional resident (Resident #24) whose medications were stored in the Nurse Station 2 medication administration cart. The facility also failed to ensure appropriate hand hygiene, appropriate glove use, and appropriate cleaning technique were implemented during Resident #29's catheter care affecting one resident (Resident #29) of two residents reviewed for catheter care. Residents Affected - Few Findings include: 1. Review of Resident #24's medical record revealed the resident was admitted on [DATE] with diagnoses including hemiplegia, type two diabetes and chronic obstructive pulmonary disease. Review of Resident #24's physician orders revealed an order dated 10/30/24 for sliding scale insulin; inject Humalog as per sliding scale with meals for diabetes if the blood glucose test was 151 to 200 administer two units; 201 to 250 administer four units; 251 to 300 administer six units; 301 to 350 administer eight units; 351 to 400 administer 10 units and notify the provider if the blood sugar was above 400. Review of Resident #36's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, altered mental status, Parkinson's disease and type two diabetes. Review of Resident #36's physician orders revealed an order dated 04/09/24 to administer three units of Humalog fast acting insulin before meals for diabetes. Observation on 02/03/25 at 11:51 A.M. with revealed Licensed Practical Nurse (LPN) #822 obtained a BGT for Resident #24 with a result of 112 and no insulin was administered. The nurse was observed cleaning the glucometer after the BGT with a 70 percent alcohol prep pad. Observation on 02/03/25 at 12:15 P.M. revealed LPN #822 obtained Resident #36's BGT with a result of 175. She then administered three units of Humalog fast acting insulin. LPN #822 was observed cleaning the glucometer with a 70 percent alcohol prep pad. Interview on 02/03/25 at 12:20 P.M. with LPN #822 revealed she did not clean the glucometer with a bleach wipe to prevent the potential of cross-contamination of blood borne pathogens because no bleach wipes were available on her medication administration cart. Interview on 02/06/25 at 10:45 A.M. with Registered Nurse #817 confirmed two residents receive BGT's using a glucometer on the Nurse Station 2 medication cart including Residents #24 and #36. Review of the facility Disinfection of Noncritical Patient Care Equipment policy last reviewed 11/18/24 revealed to clean and disinfect the patient care equipment with an EPA (Environmental Protection Agency) approved and facility approved disinfectant following the label's safety precautions and directions for use. Review of the Food and Drug Administration (FDA) guidance on Blood Glucose Meters or BGT machines (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366274 If continuation sheet Page 7 of 9 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 02/06/2025 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 Level of Harm - Minimal harm or potential for actual harm revealed the disinfection solvent chosen should be effective against HIV, Hepatitis C, and Hepatitis B virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus was the most difficult to kill. Please note that 70 percent ethanol solutions were not effective against viral bloodborne pathogens and the use of 10 percent bleach solutions may lead to physical degradation of the device. Residents Affected - Few Review of the undated Evencare G2 glucometer manufacturer directions revealed the meter and lancing device were validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. Bleach disinfectants were validated for disinfecting the meter and lancing device including Dispatch Hospital Cleaner with Bleach, Medline Micro-Kill Disinfecting Wipes; Clorox Healthcare Bleach Germicidal and Medline Micro-Kill Bleach Germicidal Bleach Wipes. 2. Review of the medical record for Resident #29 revealed an admission date of 02/02/22 with diagnoses including unspecified dementia, paranoid schizophrenia, hyperlipidemia, benign neoplasm of the colon, constipation, bilateral age-related nuclear cataracts, transient cerebral ischemic attack, benign prostatic hyperplasia (BPH), and obstructive and reflux uropathy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 12/27/24 revealed Resident #29 had intact cognition and required moderate assistance with toileting hygiene. Further review of the MDS revealed Resident #29 had an indwelling catheter and was frequently incontinent of bowel. Review of the care plan dated 06/03/22 (last reviewed 10/15/24) revealed Resident #29 was at risk for urinary tract infection and catheter-related trauma related to the presence of an indwelling catheter for urinary retention, BPH, and obstructive uropathy. Intervention included observation, documentation and reporting of catheter related discomfort, monitoring and reporting signs and symptoms of infection, and providing catheter care per policy. Review of the physician orders revealed an order dated 12/12/24 for Resident #29 to have catheter care every shift. Observation on 02/05/25 from 3:10 P.M. to 3:15 P.M. revealed Resident #29 received catheter and perineal care from Certified Nurse Aide (CNA) #828, assisted by CNA #831. The Director of Nursing (DON) was also present for the observation and verbally instructed the CNAs Remember to change your gloves prior to them beginning the procedure. Further observation revealed that soap was added to the wash basin and the same basin was used for both washing and rinsing the catheter and perineal area. During the observation, CNA #828 wore the same gloves throughout the entire procedure, including washing and rinsing (with soapy water) the catheter , which had a small clump of a dried, sticky substance on it, and providing perineal area, pulling up Resident #29's dry brief and pants, straightening his bedding, and adjusting the bed height. Interview on 02/05/25 at 3:18 P.M. with CNA #828 confirmed she used the soapy water to rinse the catheter and perineal area but should have used clean water. Further interview with CNA #828 confirmed she did not change her gloves between washing the catheter and perineal area and then completing the rest of the clean procedure with soiled gloves. During the interview, CNA #828 revealed she was unaware gloves should be changed between moving from a soiled task to a clean task and stated, I never knew that. Review of the Centers for Disease Control (CDC) and Prevention website guidance titled Clinical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366274 If continuation sheet Page 8 of 9 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 02/06/2025 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 Level of Harm - Minimal harm or potential for actual harm Safety: Hand Hygiene for Healthcare Workers revealed gloves should be changed if gloves became soiled with body fluids, after a task, and when moving from work on a soiled body site to a clean site, even when on the same person. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366274 If continuation sheet Page 9 of 9