A list of the most recent deficiencies for The Laurels of Chagrin Falls. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-22 | 2023-07-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-22 | 2023-07-12 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-02-17 | 2023-03-15 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-02-17 | 2023-03-15 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-12-12 | 2023-01-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-12 | 2023-01-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-12 | 2023-01-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-12 | 2023-01-09 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-12-12 | 2023-01-09 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-12-12 | 2023-01-09 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-12-12 | 2023-01-09 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-12 | 2023-01-09 | N |
| 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. | Health | 2022-12-12 | 2023-01-09 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-12-12 | 2023-01-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-12 | 2023-01-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-12 | 2023-01-09 | N |
| Provide activities to meet all resident's needs. | Health | 2022-12-12 | 2023-01-09 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-12-05 | 2023-01-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-05 | 2023-01-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-05 | 2023-01-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-05 | 2023-01-09 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-01 | 2022-10-06 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-09-01 | 2022-10-06 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-09-01 | 2022-10-06 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-01 | 2022-10-06 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-28 | 2022-04-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-28 | 2022-04-22 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-28 | 2022-04-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-28 | 2022-04-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-19 | 2021-12-13 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-19 | 2021-12-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-11-19 | 2021-12-13 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-19 | 2021-12-13 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-11-19 | 2021-12-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-19 | 2021-12-13 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-04-18 | 2021-04-21 | Y |
| Provide activities to meet all resident's needs. | Health | 2020-01-04 | 2020-03-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-04 | 2020-03-03 | N |
| 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. | Health | 2020-01-04 | 2020-03-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-04 | 2020-03-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-04 | 2020-03-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Develop a communication plan. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Use approved construction type or materials. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-02 | 2020-03-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-11-15 | 2019-02-22 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-11-15 | 2019-02-01 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-11-15 | 2019-02-01 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2018-11-15 | 2019-02-01 | N |
| 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. | Health | 2018-11-15 | 2019-02-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-15 | 2019-02-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-11-15 | 2019-02-01 | N |
| Meet other general requirements. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-15 | 2019-02-01 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-11-15 | 2019-01-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-11-15 | 2019-01-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-11-15 | 2019-01-31 | N |
