Inspection·June 1, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for Resident #7 to include anticoagulant use. This affected one resident (#7) of five residents who were reviewed for care plans with high-risk medications. The facility census was 11. Findings include: Review of the medical record for Resident #7 revealed an admission date of 05/10/23. Diagnoses included acute on chronic systolic congestive heart failure, atrial fibrillation, essential primary hypertension, and ischemic cardiomyopathy. Review of the admission Minimum Data Set (MDS) assessment, dated 05/17/23, revealed Resident #7 had intact cognition. Resident #7 received an anticoagulant seven of the seven days prior to the assessment reference date. Review of Resident #7's physician orders effective May 2023 revealed Eliquis 5 milligrams (mg) twice daily for blood thinner (anticoagulant). Review of Resident #7's comprehensive care plan dated 05/24/23 revealed a focus of activities of daily living, risk for falls, alteration in nutrition status, risk for pain, and risk for skin impairment/breakdown. There was no focus or interventions for anticoagulant use. Interview on 05/31/23 at 3:07 P.M. with Registered Nurse (RN) #796 verified Resident #7's comprehensive care plan dated 05/24/23 did not contain a focus for anticoagulant use. Interview on 06/01/23 at 11:14 A.M. with Administrator indicated the facility had no policy regarding care plans and only used standard requirements. 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 06/01/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the fall care plan for Resident #76 was updated in a timely and complete manner. This affected one resident (#76) of ten resident care plans reviewed. The facility census was 11. Finding include: Resident #76 was admitted to the facility on [DATE] with diagnoses including intracerebral hemorrhage, gastrostomy status, and abnormal findings on diagnostic imaging of central nervous system. Review of the admission Minimum Data Set (MDS) assessment, dated 05/15/23, revealed Resident #76 had severely impaired cognition. The resident could sometimes make self understood and sometimes understood others. Resident #76 was totally dependent on two people for transfers. The resident was totally dependent on one person for locomotion and eating. The resident required the extensive assistance of two people for bed mobility, dressing, toilet use, and personal hygiene. The Morse Fall scale reviews completed on 05/10/23, 05/16/23, 05/18/23, 05/21/23, 05/22/23, 05/27/23, and 05/28/23 each revealed Resident #76 to be a high fall risk. Review of the plan of care dated 05/10/23 revealed the resident was at risk for falls. Interventions added on 05/10/23 included: anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs a prompt response to all requests for assistance, bed against wall per family's request, bed bolsters in place to bed, and ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. Interventions added on 05/27/23 were for the bed to be kept in the lowest position and mats to floor on both sides of the bed. Interventions added on 05/28/23 were to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, Review of the care plan dated 05/28/23 revealed Resident #76 had an actual fall with no injury, related to poor communication/comprehension on 05/28/23. Interventions included: continue interventions on the at-risk plan, determine and address causative factors of the fall, and neuro-checks to be done per facility protocol. There were no interventions added to the care plan after Resident #76's falls on 05/15/23, 05/16/23, 05/17/23, and 05/21/23 even though there were interventions in the nurse's notes and Interdisciplinary Team (IDT) notes. Resident #76's fall from 05/08/23 was reviewed by the IDT on 05/31/23. The resident's fall from 05/16/23 had a fall report done on 05/16/23 but the post fall assessment was not completed until 05/30/23. The IDT review on 05/18/23 for Resident #76's fall on 05/17/23 recommended hourly rounds, but that was added to the care plan. (continued on next page) 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 06/01/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The post fall note completed on 05/24/23 for Resident #76's fall on 05/21/23 had an intervention to place things that were grabbable, such as the resident's tube feed pole, on his left side. That was not added to the fall care plan. The IDT review done on 05/31/23 of Resident #76's fall on 05/27/23 recommended offer to toilet before bed and P.M., but that was not added to the fall care plan. Interview on 06/01/23 at 10:45 A.M. Registered Nurse (RN) #796 verified Resident #76's care plan updates were not timely and all recommended interventions were not included in the care plan. 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 06/01/2023 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to post nurse staffing data daily as required. This had the potential to affect all 11 residents residing in the facility. Residents Affected - Many Findings include: Observation on 06/01/23 at 9:40 A.M. revealed posted nurse staffing data in a plastic sign holder which was displayed on the receptionist desk at the front entrance of the facility. The posted nurse staffing data was dated 05/30/23. Interview at the time of the observation with Receptionist #819 verified the posted nurse staffing data displayed was dated 05/30/23. Receptionist #819 removed the nurse staffing data from the plastic sign holder which also held nurse staffing data sheets dated for 05/26/23, 05/27/23, 05/28/23 and 05/29/23. There were no nurse staffing data sheets for 05/31/23 and 06/01/23. Receptionist #819 stated the facility scheduler provided the nurse staffing data sheets for posting and was off from work and did not provide the prepared sheets for 05/31/23 and 06/01/23. Observation and interview on 06/01/23 at 10:11 A.M. with Receptionist #819 indicated the nurse staffing data sheets for 05/31/23 and 06/01/23 were now completed and 06/01/23 would be posted. Observation at the time of the interview revealed the completed nurse staffing data sheets for 05/31/23 and 06/01/23. 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 06/01/2023 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 and interview the facility failed to ensure all medications were stored appropriately in medication carts. This had the potential to affect all 11 residents residing in the facility. Findings include: Observation of the medication carts completed on 05/30/23 at 9:15 A.M. revealed there were a total of 23 loose medications observed. There were 13 loose medications observed in the Cherry Hill medication cart, as well as 10 loose medications and a yellow powder spilled throughout the top drawer of the Maple Lane medication cart. The facility had a total of two medication carts. Interview on 05/30/23 at 9:30 A.M. with Registered Nurse (RN) #801 revealed she confirmed there were 13 loose medications observed in the Cherry Hill medication cart, as well as 10 loose medications and a yellow powder spilled throughout the top drawer of the Maple Lane medication cart. 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 06/01/2023 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 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 and interview, the facility failed to maintain the overhead hood vents, fire suppression nozzles, and backsplash behind the stove in a clean, sanitary, and safe manner. This had the potential to affect ten of the eleven residents residing in the facility. Resident #76 did not receive food from the facility kitchen. The facility census was 11. Findings include: A tour of the kitchen on 05/30/23 from 9:15 A.M. through 9:44 A.M. with Dietary Manager #821 revealed the overhead vents and the fire suppression nozzles were greasy and had accumulated dust. The backsplash behind the stovetop was greasy. Dietary Manager #821 verified the condition of the hood, nozzles, and back splash at the time of the observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366379 If continuation sheet Page 7 of 7