The Laurels of Chagrin Falls

In the surveyor’s words

From the most serious findings on record at The Laurels of Chagrin Falls, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Nov 19, 2021

  Based on observation, record review, interview, review of staffing and medication administration policies, job description of the Director of Nursing (DON) and facility assessment, the facility administration, having knowledge of resident care not being delivered, failed to implement its resources to ensure all residents received appropriate care to attain and maintain the highest practicable level of physical, mental, and psychosocial well-being. The facility failed to ensure a licensed nurse was assessing, monitoring, and treating residents on 10/31/21 from 7:00 A.M. to 7:00 P.M. on the COVID-19 unit that housed six residents (Resident's #8, #15, #18, #31, #37 and #43). […]

• Immediate jeopardy, patternF600Nov 19, 2021

  Based on interviews, observation, open and closed record review, and review of the facility policy and procedure regarding abuse and neglect prohibition the facility failed to implement an effective and appropriate process to meet the care planned needs of six residents residing on the COVID-19 positive unit (Resident's #8, #15, #18, #31, #37 and #43) on 10/31/21 from 7:00 A.M. to 7:00 P.M. when no licensed nursing staff addressed the administration of medications, pain management, skin treatments, assessments of respiratory status or vital signs that were ordered by the physician. The facility administration failed to resolve the situation, and the COVID-19 unit remained without a licensed nurse on 10/31/21 from 7:00 A.M. to 7:00 P.M. […]

• Immediate jeopardy, patternF725Nov 19, 2021

  Based on record review, interviews, review of staffing policies, job description of the Director of Nursing (DON) and facility assessment, the facility failed to ensure a licensed nurse was assigned to care for six residents (Resident's #8, #15, #18, #31, #37 and #43) residing on the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. resulting in no licensed care being completed including the administration of medication, administration of skin treatments, respiratory assessments, blood glucose checks, and vital signs as ordered. The facility had one agency nurse, Registered Nurse (RN) #611, on duty for the resident population of 43 residents and she did not include the care of the residents on the COVID-19 unit. […]

• Immediate jeopardy, patternF760Nov 19, 2021

  Based on interview, observation, record review, review of facility policy and procedure regarding diabetic management, medication administration, and pain management the facility failed to ensure medications were administered on the COVID-19 unit on 10/31/21 from 7:00 A.M. to 7:00 P.M. resulting in significant medications errors affecting four residents (Resident's #8, #18, #31 and #43) residing on the COVID-19 unit. This resulted in Immediate Jeopardy that caused actual harm for four residents, (Residents #8, #18, #31 and #43) due to the failure to administer significant medication. On 10/31/21 at 7:30 A.M. […]

• Immediate jeopardy, isolatedF697Nov 19, 2021

  Based on observation, record review, review of facility policy and procedure related to pain management and interviews with facility staff the facility failed to address two residents' (Resident's #8 and #31) request for pain management resulting in Resident #8 and Resident #31 experiencing intolerable pain that caused them to cry out over an extended time period on 10/31/21 on the 7:00 A.M. to 7:00 P.M. shift. On 10/31/21 from 7:00 A.M.to 7:00 P.M. the facility had knowledge that one nurse, RN #611, was assigned to the entire resident population of 43 residents. RN #611 did not provide any care to the residents residing on the COVID-19 unit including assessment of pain for two residents (Residents #8 and #31) from 7:00A.M. through 7:00 P.M. […]