Health inspection·January 22, 2026

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. Based on observation, interview, record review and review of facility policy, the facility failed to appropriately cover an indwelling urinary catheter drainage bag with a dignity/privacy pouch. This affected one resident (#33) out of three residents reviewed for urinary catheters and had the potential to affect seven residents (#6, #10, #14, #19, #22, #25 and #33) identified by the facility with urinary catheters. The facility census was 22.Findings include: Review of the medical record for Resident #33 revealed an admission date of 01/19/26 and his diagnoses included benign prostatic hyperplasia (enlargement of the prostate causing urinary issues) with lower urinary tract symptoms, chronic kidney disease, and diabetes. Review of January 2026 physician orders revealed Resident #33 had an order for an indwelling urinary catheter and catheter care was to be provided every shift. Observation on 01/20/26 at 9:16 A.M. revealed Resident #33 was lying in a bed with his indwelling urinary catheter drainage bag on the side of his bed with part of the bag laying on the floor. From the hallway, yellow urine of approximately 100 cubic centimeters (cc) was seen as there was no dignity/privacy pouch covering the catheter drainage bag. Interview on 01/20/26 at 9:16 A.M. with Resident #33 revealed he was pleasantly confused regarding the privacy of his catheter. Interview on 01/20/26 at 9:18 A.M. with Licensed Practical Nurse (LPN) #222 verified Resident #33's indwelling urinary catheter drainage bag was not covered with a dignity/privacy pouch and from the hallway, urine was seen inside his drainage bag. Review of Baseline Care Plan dated 01/21/26 revealed Resident #33 had an indwelling catheter and was dependent on staff for his toileting hygiene. There was nothing in the care plan about providing a dignity pouch to cover his urinary catheter drainage bag.Review of facility policy labeled, Resident Rights, dated 11/28/16 revealed all residents had the right to be treated with dignity and respect. There was nothing in the policy regarding ensuring privacy/dignity in relation to covering an indwelling catheter drainage bag. This deficiency represents non-compliance investigated under Complaint Number 2599654. Page 1 of 6 366379 366379 01/22/2026 Eliza at Chagrin Falls 16695 Chillicothe Road Chagrin Falls, OH 44023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy, the facility failed to provide showers/bathing per resident preference and schedule. This affected six residents (#10, #11, #14, #25, #34 and #37) out of 22 residents reviewed for showers. The facility census was 22.Findings include:1. Review of the medical record for Resident #25 revealed an admission date of 06/15/24 with diagnoses of metabolic encephalopathy, acute cystitis (bladder infection), dementia, heart failure, anxiety disorder, delirium, and malignant neoplasm of trachea. Residents Affected - Some Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive decline. The resident required moderate assistance for all activities of daily living (ADL) including grooming, hygiene, and toileting needs. Resident #25 was dependent on staff for all mobility and transfer needs and utilized a wheelchair. The resident was always incontinent of bowel and bladder. Review of Resident #25's physician orders effective January 2026 revealed Resident #25 was to receive showers and skin checks twice weekly every Wednesday and Saturday per resident preference. Interview on 01/20/26 at 9:40 A.M. with Resident #25 revealed she had not received scheduled showers twice weekly per her preference. The resident stated it had been a while since she had a shower and would like them to restart. Resident #25 could not recall the last time she received a shower/bed bath. Interview with Certified Nursing Assistant (CNA) #208 on 01/22/25 at 7:25 A.M. revealed showers were scheduled twice weekly or more per resident preference. All showers were documented on a shower sheet for each resident and given to the Director of Nursing (DON) upon completion. Both the CNA and nurse sign off on all shower sheets and include documentation of skin checks for that resident. CNA #208 revealed if a resident refused a shower, the CNAs attempted again later that day and notified the nurse who provided re-education to the resident regarding the importance of showers/bed baths. CNA #208 stated that any refusals for showers/bed baths by a resident were documented in the progress notes and in the CNA tasks in the electronic medical record (EMR). Review of shower sheets for the last two months (December 2025 to January 2026) for Resident #25 revealed only two showers were documented, 12/31/25 and 01/07/26. Review of progress notes for Resident #25 revealed one documented shower refusal on 01/18/26. Review of CNA tasks in Resident #25's EMR revealed only one shower was documented on 12/26/25 from December 2025 to January 2026. Interview with the DON on 01/22/26 at 11:45 A.M. verified the missed showers for Resident #25 including the lack of shower/bathing documentation. 2. Review of the medical record for Resident #10 revealed an admission date of 01/05/26 with diagnoses including quadriplegia, malignant neoplasm of the spinal cord, and muscle wasting. Review of January 2026 physician orders revealed Resident #10 had an order dated 01/07/26 to schedule and complete skin checks twice weekly on bath/shower days in the morning every Wednesday and 366379 Page 2 of 6 366379 01/22/2026 Eliza at Chagrin Falls 16695 Chillicothe Road Chagrin Falls, OH 44023

F 0677 Sunday. Level of Harm - Minimal harm or potential for actual harm Review of the care plan dated 01/05/26 revealed Resident #10 had an ADL functional performance deficit being dependent on staff for assistance. Interventions included for staff to provide assistance to maintain hygiene, adjust clothing, roll from lying on the back to left and right, transfers to bed to chair, and for dressing. Residents Affected - Some Review of the five-day MDS assessment dated [DATE] revealed Resident #10 had intact cognition. He was dependent on staff assistance for showers/bathing, rolling left and right and transfers. Review of facility Shower Sheets revealed Resident #10 had a shower on 01/07/26 and on 01/18/26. The shower sheet dated 01/18/26 indicated Resident #10's wife assisted him with his shower. Interview on 01/20/26 at 11:48 A.M. with Resident #10 revealed he did not feel there was enough staff as he had been at the facility for three weeks and only had two showers. He was scheduled for and preferred to have a shower twice a week on Wednesday and Sunday. He had to have his wife come in and give him a shower on 01/17/26, since the facility had missed the previous two scheduled showers on 01/11/26 and 01/14/26. Staff had stated they were unable to give him a shower on those days as they did not have time. Interview on 01/22/26 at 9:30 A.M. with Agency CNA #231 revealed she came to the facility approximately six times a month and was unable to get all her scheduled showers/baths completed as there were too many assigned to be able to get done. Interview on 01/22/26 at 11:44 A.M. with Interim DON revealed Resident #10 was to receive a shower twice a week as scheduled as well as per his preference. She verified Resident #10 had received only two showers since admission on [DATE]. She also verified the shower sheet completed on 01/18/26 should have been dated 01/17/26 (Saturday) as she had assisted Resident #10 to his shower chair so Resident #10's wife could give him a shower. She verified Resident #10 did not receive a shower or bath from 01/08/26 to 01/16/26 (nine days) including on his scheduled shower days, 01/11/26 (Sunday) and 01/14/26 (Wednesday). She revealed there had been a problem with showers getting completed and had not found a solution yet. She stated she was going to go over the issue at the next staff meeting. 3. Review of the medical record for Resident #34 revealed an admission date of 01/13/26. On 01/22/26, the resident was sent to the hospital emergency room (ER). His diagnoses included malignant neoplasm to his prostate, diabetes, and hypertension. Review of January 2026 physician orders revealed Resident #34 had an order dated 01/16/26 to schedule and complete skin checks twice weekly on bath/showers days every night shift on Monday and Friday. Review of baseline care plan dated 01/15/26 revealed Resident #34 was cognitively intact and under the shower and bathing section he was not assessed for his ability. He required partial to moderate assistance with transfers. Review of facility Shower Sheets revealed one shower sheet since Resident #34's admission that was dated 01/16/26 at 9:00 P.M., completed by CNA #208. The sheet revealed he was offered a shower and Resident #34 had refused as he stated he was tired. Interview at the time of the review with the Administrator verified the sheet was filled out on 01/22/26. 366379 Page 3 of 6 366379 01/22/2026 Eliza at Chagrin Falls 16695 Chillicothe Road Chagrin Falls, OH 44023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 01/20/26 at 9:27 A.M. with Resident #34 and Resident #34's wife revealed the biggest concern they had with the facility was not receiving a bed bath since he was admitted to the facility. Resident #34 stated the staff had not washed him since he was admitted and he felt dirty. Interview on 01/21/26 at 3:07 P.M. with the Administrator verified there were no shower/bath sheets for Resident #34 from the date Resident #34 was admitted on [DATE] until 01/21/26 (nine days). Interview on 01/22/26 at 8:45 A.M. with the Administrator revealed he interviewed staff that had provided care for Resident #34 to find out why there were no shower/bath sheets and found CNA #208 had offered Resident #34 a shower/bed bath on 01/16/26 but he had refused. CNA #208 had not filled out a shower/bath sheet until today, 01/22/26. Interview on 01/22/26 at 9:30 A.M. with Agency CNA #231 revealed she came to the facility approximately six times a month and was unable to get all her showers/baths completed as scheduled as there were too many assigned to be able to get done. Interview on 01/22/26 at 11:44 A.M. with Interim DON revealed Resident #34 was scheduled to receive a shower and/or bath twice a week. The only shower/bath sheet was dated 01/16/26 (that was filled out on 01/22/26). She verified she had no documentation Resident #34 was offered or given a shower/bath from 01/17/26 to 01/22/26 (six days) including on 01/19/26, his scheduled shower/bath day. She stated there had been a problem with showers getting completed and had not found a solution yet. She was going to go over the issue at the next staff meeting. 4. Review of the closed medical record for Resident #37 revealed an admission date of 08/01/25 and discharge to home on [DATE]. His diagnoses included fracture of right arm, hypertension, unsteadiness on feet, muscle weakness and history of falling. Review of August 2025 physician orders for Resident #37 revealed an order dated 08/01/25 to schedule and complete skin checks twice weekly on bath/shower days every nightshift on Tuesday and Saturday, and an order dated 08/19/25 to schedule and complete skin checks twice weekly on bath/shower days every dayshift on Tuesday and Saturday. Review of the five-day MDS assessment dated [DATE] revealed Resident #37 had impaired cognition. He required substantial to maximum staff assistance with lower body dressing and transfers. He was dependent on staff for rolling left and right in bed. The assessment indicated showers/bathing were not attempted due to medical condition and/or safety concerns. Review of facility Shower Sheets revealed Resident #37 had a bed bath on 08/12/25 and 08/26/25. Review of the care plan dated 08/16/25 revealed Resident #37 had an ADL functional performance deficit being dependent on staff for assistance. Interventions included for staff to provide assistance with hygiene, adjusting clothes, rolling left and right in bed, and substantial to maximum assistance with transfers. Interview on 01/22/26 at 9:30 A.M. with Agency CNA #231 revealed she came to the facility approximately six times a month and stated she was unable to get all her showers/baths completed as scheduled as there were too many assigned to be able to get done. Interview on 01/22/26 at 11:44 A.M. with Interim DON revealed Resident #37 was scheduled to receive 366379 Page 4 of 6 366379 01/22/2026 Eliza at Chagrin Falls 16695 Chillicothe Road Chagrin Falls, OH 44023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a shower and/or bath twice a week and there was no medical reason why Resident #37 could not at least receive a bed bath during his stay. She verified the facility only had two shower sheets for Resident #37 during his stay, on 08/12/25 and 08/26/25, and there was no evidence Resident #37 received a shower from 08/01/25 to 08/11/25 (11 days) and from 08/13/25 to 08/25/25 (13 days). She stated there had been a problem with showers getting completed and had not found a solution yet. She was going to go over the issue at the next staff meeting. 5. Review of the medical record for Resident #11 revealed an admission date of 08/23/24. Diagnoses included macular degeneration, Crohn's disease, osteoarthritis, and a history of falling. Review of the quarterly MDS assessment dated [DATE] revealed Resident #11 had intact cognition. The resident used a wheelchair for mobility and required partial/moderate assistance for showers/baths, sit to stand, and transfers. Review of physician orders effective January 2026 revealed Resident #11 was to receive showers and skin checks twice weekly on Wednesdays and Saturdays. Review of the shower sheets for the last two months (December 2025 to January 2026) revealed Resident #11 received a shower on 12/06/25 and 12/10/25. Thereafter, there was a ten-day gap before a shower was received on 12/20/25. The resident then had a shower on 12/24/25 and refused a shower on 12/27/25. Afterwards, the resident did not receive another shower until 01/10/26 which was 14 days from the previous shower. Ten days after that Resident #11 received a shower on 01/17/26. Interview on 01/20/26 at 11:32 A.M. with Resident #11 stated she didn't get her showers when she was supposed to. Interview on 01/21/26 at 3:07 P.M. with the Administrator verified there were no additional shower/bath sheets for Resident #11. Interview on 01/22/26 with CNA #208 revealed Resident #11 required total care, could assist and was able to stand and pivot. The resident did not refuse care. Interview on 01/22/26 at 9:30 A.M. with Agency (CNA) #231 revealed she came to the facility approximately six times a month and stated she was unable to get all her scheduled showers/baths completed as there were too many assigned to be able to get done. Interview on 01/22/26 at 11:44 A.M. with Interim DON revealed Resident #11 was to receive a shower twice a week as scheduled as well as per preference. She verified that those were all the shower sheets available for Resident #11. She stated there had been a problem with showers getting completed and had not found a solution yet. She was going to go over the issue at the next staff meeting. 6. Review of the medical record for Resident #14 revealed an admission date of 01/02/26. Diagnoses included displaced intertrochanteric fracture, diabetes, congestive heart failure, and a history of falling, Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had intact cognition. The resident was one-person physical assistance with showers/bathing. Review of physician orders effective January 2026 revealed Resident #14 was to have showers and 366379 Page 5 of 6 366379 01/22/2026 Eliza at Chagrin Falls 16695 Chillicothe Road Chagrin Falls, OH 44023

F 0677 skin checks twice weekly on Mondays and Thursdays. Level of Harm - Minimal harm or potential for actual harm Review of the shower sheets from admission for Resident #14 revealed the resident received a bed bath on 01/20/26. There were no other shower sheets. Residents Affected - Some Interview on 01/20/26 at 1:50 P.M. with Resident #14 stated she didn't get enough showers. Interview on 01/21/26 at 3:07 P.M. with the Administrator verified there were no additional shower/bath sheets for Resident #14. Interview on 01/22/26 at 9:30 A.M. with Agency (CNA) #231 revealed she came to the facility approximately six times a month and stated she was unable to get all her scheduled showers/baths completed as there were too many assigned to be able to get done. Interview on 01/22/26 at 11:44 A.M. with Interim DON revealed Resident #14 was to receive a shower twice a week as scheduled as well as per preference. She verified that those were all the shower sheets available for Resident #14. She stated there had been a problem with showers getting completed and had not found a solution yet. She was going to go over the issue at the next staff meeting. Review of facility policy labeled, Hygiene, Bathing, and Showering Policy, revised 2023 revealed the facility provided assistance with personal hygiene, bathing, and showering to maintain residents' comfort, dignity, health, and quality of life. Hygiene and bathing services were provided in accordance with the residents' needs and preferences. This deficiency represents non-compliance investigated under Complaint Number 2599654. 366379 Page 6 of 6