Inspection·April 29, 2021

F 0695 Level of Harm - Minimal harm or potential for actual harm Observation on 04/26/21 at 1:29 P.M. revealed Resident #123 in bed with oxygen nasal cannula in place, oxygen setting was at two LPM, and the oxygen tubing was not dated. Observation on 04/27/21 at 7:54 A.M. revealed Resident #123 was sitting up in a chair with oxygen nasal cannula in place, oxygen setting was at two LPM, and the oxygen tubing was not dated. Residents Affected - Few Observation on 04/27/21 at 11:24 A.M. with RN #250 of Resident #123 confirmed the oxygen nasal cannula was in place, oxygen was set at two LPM, and the oxygen tubing was not dated. RN #250 indicated oxygen tubing required dating for weekly replacement. Interview on 04/29/21 at 12:36 P.M. with RN #251 confirmed there were no physician orders for oxygen administration, and verified the nurses should document administering oxygen in the MAR. Review of the facility policy titled Respiratory Therapy and Care of Equipment, revised September 2017, revealed oxygen tubing and the delivery device (nasal cannula or mask) will be changed routinely once a week, equipment will be dated when changed by both the nursing staff and the oxygen company. Review of the facility education of policy titled Oxygen Administration Process, dated 04/27/21 to 04/28/21, revealed oxygen tubing will be labeled with the patients name and date, and verify that there is a physician's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366379 If continuation sheet Page 2 of 7 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 366379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eliza at Chagrin Falls 16695 Chillicothe Road Chagrin Falls, OH 44023 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 - Many 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. 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 A.M. with RN #252 of medication cart storage revealed an injectable pen of Ozempic (anti-diabetic medication) 2.5 milligrams per 1.5 milliliter stored in the top drawer of the medication cart labeled maple. The Ozempic injectable pen was observed to be previously used, was not dated, was not labeled, and was not in a labeled storage box or container. Review of the facility policy titled Storage of Medication/Nutritional Supplements, reviewed February 2021, revealed medications/nutritional supplements shall be stored in the packaging, containers or other dispensing systems in which they are received, and medication containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Review of the facility policy titled Insulin Storage, reviewed March 2021, revealed opened insulin will be dated the day it is opened. Review of the facility policy titled Medication Administration, dated 09/14/20, revealed prepare medications according to orders and standard of practice/ensuring to check package open dates/expiration dates. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366379 If continuation sheet Page 3 of 7 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 366379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eliza at Chagrin Falls 16695 Chillicothe Road Chagrin Falls, OH 44023 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, 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. Residents Affected - Many 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 staff assistance for transfers, and was always continent of urine and bowel. The assessment did not indicate isolation or quarantine. Review of Resident #70's medical record revealed no documented immunization information for COVID-19. Review of the physician's orders dated 04/16/21 revealed quarantine 14 days, transmission based respiratory droplet and contact precautions every shift until 04/27/21. Review of the progress notes dated 04/16/21 revealed transmission based precautions (TBP) were in place. There was no documentation of TBP prior to 04/16/21. Interview on 04/29/21 at 1:36 P.M. with RN #251 confirmed TBP were not ordered until 04/16/21, three days after Resident #70's admission from the hospital on [DATE], and there was no documentation TBP were initiated prior to 04/16/21. Registered Nurse (RN) #251 indicated TBP were required for COVID-19 because the resident had a hospital stay and there was no documentation of COVID-19 vaccination. Observation on 04/27/21 at 8:44 A.M. with RN #252 during medication administration revealed on the door of Resident #70's room two posted signs, Droplet Precautions and Contact Precautions. Review of the facility TBP sign, Contact Precautions, undated, revealed everyone must clean their hands, including before entering and when leaving the room. Further review of Contact Precautions sign indicated the source was the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Review of the facility TBP sign, Droplet Precautions, undated, revealed everyone must clean their hands, including before entering and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry, and remove face protection before room exit. Further review of Droplet Precautions sign revealed pictures to indicate use of face shield or goggles for face protection, and indicated the source was the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366379 If continuation sheet Page 4 of 7 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 366379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eliza at Chagrin Falls 16695 Chillicothe Road Chagrin Falls, OH 44023 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 Residents Affected - Many 2. Observation on 04/27/21 at 8:46 A.M. with RN #252 during medication administration revealed RN #252, who was wearing an N95 (respirator) mask and face shield, donned a gown and gloves, and enter Resident #70's room. Observed standing next to Resident #70's bed was a visitor wearing no personal protective equipment (PPE). RN #252 requested the visitor put on a surgical mask, which the visitor complied, and did not request the visitor wear any additional PPE including a face shield or goggles, gloves or a gown. The visitor then left Resident #70's room indicating a need to obtain a cup for the resident. Upon exiting the room, the visitor did not perform handwashing and walked to the common dining area, obtained a Styrofoam cup and re-entered Resident #70's room still wearing a surgical mask. Upon entry, the visitor did not perform handwashing and did not put on any additional PPE including a face shield or goggles, gloves or a gown. RN #252 then exited Resident #70's room after removing the gown, gloves and performing handwashing. RN #252 did not change the N95 mask which was unprotected by a surgical mask, and did not disinfect the face shield or change the face shield. Interview with RN #252 at the time of the observation confirmed the above findings and indicated an understanding that visitors only had to wear surgical masks including residents on TBP. Interview on 04/27/21 at 9:57 A.M. with Unit Clerk #300 verified visitors were pre-scheduled and educated with guidelines for wearing a surgical mask with visits. Unit Clerk #300 indicated no one visited when on TBP unless approved by management. Review of the visit schedule titled Rehab Pavilion, dated 04/27/21, revealed a visitor scheduled for Resident #70 at 10:30 A.M. Resident #70 was not identified on the list with a requirement for TBP. Interview on 04/27/21 at 11:36 A.M. with RN #251 confirmed visitors for residents in TBP were educated to wear a gown, face shield and an N95, and to perform handwashing before and after leaving the resident's room. RN #251 indicated activity staff monitored visitors and helped ensure guidelines were followed. Interview on 04/27/21 at 12:50 P.M. with Activities #302 verified visits were pre-scheduled and the information was provided to nursing staff. Activities #302 confirmed visitors for residents in TBP were to wear a mask and gown, and Unit Clerk #300 would use the schedule to know which residents were on TBP to educate visitors as they arrived or nursing staff would do the same as needed. Interview on 04/27/21 at 1:20 P.M. with Housekeeping #303 confirmed with residents in TBP, the N95 mask had to be covered with a surgical mask upon entry or the N95 mask changed upon exit of the room, and the face shield or goggles disinfected upon exit of the room. Interview on 04/27/21 at 2:12 P.M. with RN #251 verified when exiting resident rooms with TBP, the face shield or goggles had to be disinfected or changed. Interview on 04/27/21 at 2:23 P.M. with Infection Preventionist (IP) #304 confirmed residents admitted and not vaccinated for COVID-19 are placed on TBP for 14 days. IP #304 verified visitors for residents on TBP were required to wear a surgical mask, face shield, and gown, and use handwashing prior to entering and when exiting the room. Interview on 04/28/21 at 9:23 A.M. with Unit Clerk #300 verified the visitation schedule dated 04/27/21 did not have residents identified with TBP including Resident #70, and confirmed when Resident #70's visitor arrived on 04/27/21, the visitor was not educated on TBP as required. Review of the facility policy titled COVID-19: PPE Use During Pandemic, dated 02/10/20, all staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366379 If continuation sheet Page 5 of 7 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 366379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eliza at Chagrin Falls 16695 Chillicothe Road Chagrin Falls, OH 44023 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 will wear a face shield in all patient care areas when in Yellow (staff working in a designated space where no active, suspected or isolation cases of COVID-19 are noted) and Red (staff working in a designated space with confirmed cases of COVID-19 on the unit/facility) zones. The face shield will be disinfected at the beginning of the work day, after every patient care encounter and at the end of the work day with a facility approved disinfectant per CDC (Centers for Disease Control) disinfection guidelines. Residents Affected - Many Review of the facility policy titled COVID-19: Visitation and Communal Activities, dated 01/25/21, revealed residents who are on transmission-based precautions for COVID-19 should only receive visits that are virtual, through windows, or in-person for compassionate care situations, with adherence to transmission-based precautions. 3. Record review revealed Resident #119 was admitted on [DATE] with diagnoses including sepsis, urinary tract infection, chronic obstructive pulmonary disease (COPD) and congestive heart failure. Review of care plan dated 04/24/21 revealed the resident had a self-care performance deficit with activities of daily living. Interventions included to provide one staff assistance with bed mobility, toileting, transfers, dressing and bathing, and encourage the resident to participate to the fullest extent possible. Observation on 04/27/21 at 11:07 A.M. with RN #250 during medication administration revealed soiled linen on Resident #119's bathroom floor adjacent to the sink, soiled towels on Resident #119's bathroom shower floor, and soiled clothing on Resident #119's bathroom floor adjacent to the bathroom door. Interview with RN #250 at the time of the observation confirmed the above findings and indicated soiled laundry should be bagged and placed in the soiled laundry area and not left on a resident's floor. Review of the facility education of policy titled Soiled Linen, dated 04/27/21 to 04/28/21, revealed make sure the soiled linen is properly handled from the point of collection to the laundry, and treat all soiled linen as potentially infectious. 4. Resident #9 was admitted on [DATE] with diagnoses including hypertensive heart disease, cognitive communication deficit, osteoporosis, diabetes and a history of falling. Review of physician orders revealed and order dated 04/15/21 for quarantine for 14 days, Transition Based, Respiratory Droplet and Contact Precautions. Review of the immunization record for the resident was negative for any COVID-19 vaccine. The care plan dated 04/15/21 revealed a care area for at risk of respiratory illness, COVID-19 with an intervention of Institute isolation precautions as individually appropriate. Observation of and interview with State Tested Nurse Aide (STNA) #205 on 04/28/21 9:01 A.M. revealed the STNA exited Resident #9's room wearing a face shield and face mask but no gown. The door to the room had isolation signs prominently displayed and personal protection equipment (PPE) including surgical masks, gowns and gloves hanging on the door. The STNA verified she should have donned a gown and wiped her face shield. Interviews on 04/27/21 at 2:12 P.M. with RN #251 verified staff need to wipe or change their face shield when exiting isolation rooms. Review of the COVID-19: PPE Use During Pandemic policy dated 02/10/20 revealed : all staff will wear a face shield in all patient care areas when in Yellow (staff working in a designated space where no active, suspected or isolation cases of COVID-19 are noted) and Red (staff working in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366379 If continuation sheet Page 6 of 7 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 366379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eliza at Chagrin Falls 16695 Chillicothe Road Chagrin Falls, OH 44023 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 Residents Affected - Many designated space with confirmed cases of COVID-19 on the unit/facility) zones. The face shield will be disinfected at the beginning of the work day, after every patient care encounter and at the end of the work day with a facility approved disinfectant per CDC. 5. Resident #126 was admitted on [DATE] with diagnoses including acute neoplastic leukemia not having achieved remission and Alzheimer's disease. Review of physician orders revealed an order of 04/23/21 for quarantine for 14 days, transmission based respiratory droplet and contact precautions every shift until 05/06/21. Review of the immunization record for the resident was negative for any COVID-19 vaccine. The care plan dated 04/21/21 revealed care areas included impaired immunity related to leukemia with recent chemotherapy with a risk for contracting infections due to impaired immune status and an intervention to keep the environment clean and people with infection away. The care plan revealed a second care area was for risk of COVID-19 with an intervention to institute isolation precautions as individually appropriate. Interview on 04/27/21 at 11:36 A.M. with RN #251 revealed visitors for residents on isolation are educated to wear a gown and face shield and an N95 and to wash hands before and after leaving the room. Activities staff monitor the visitors and the visits are pre-scheduled and monitored by them, and they go over the guidelines with them. Observation on 04/27/21 at 4:15 P.M. revealed Resident #126's daughter was visiting in his room, wearing a surgical mask and no face shield or goggles and no personal protective gown. The door to the room had isolation signs prominently displayed and PPE including surgical masks, gowns and gloves hanging on the door. She was momentarily joined by Resident #126's son who was wearing a surgical mask. Interview on 04/27/21 at 4:18 P.M. with Resident #126's daughter and son revealed no staff had informed them they needed to wear a face shield and gown when visiting their father. The son reported he was not screened by anyone when he entered the building and proceeded back to his father's room with no instructions on PPE. Interview on 04/29/21 with RN #251 revealed she could find no documentation that transmission based precautions were ordered for Resident #126 upon his admission on [DATE], only the order of 04/23/21. Review of the schedule for visitors for 04/27/21 did not contain any visits for Resident #126. Review of the undated facility transmission-based precautions sign, Droplet Precautions revealed everyone must clean their hands, including before entering and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry, and remove face protection before room exit. Further review of the Droplet Precautions sign revealed pictures to indicate use of face shield or goggles for face protection, and indicated was the source of the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366379 If continuation sheet Page 7 of 7