Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eliza At Chagrin Falls during CMS and state inspections, most recent first.
Food items in the kitchen were found improperly stored, with tortilla chips, orange gelatin, diced carrots, cheddar cheese, French fries, and fried chicken left open to air or uncovered and not labeled or dated. The Dietary Mgr verified the findings during the kitchen tour, and the facility census was 22.
Multiple residents who required staff assistance with ADLs did not receive showers or bed baths as ordered or preferred, resulting in prolonged gaps between bathing events and incomplete documentation of care or refusals. Several cognitively intact and cognitively impaired residents with conditions such as dementia, quadriplegia, fractures, diabetes, heart failure, and cancer reported not receiving showers when expected, with some stating they felt dirty or that family had to assist with bathing. Review of shower sheets, EMR CNA tasks, and progress notes showed only sporadic showers, late or missing shower documentation, and long intervals without any recorded bathing, despite physician orders for twice‑weekly showers with skin checks. CNAs, including agency staff, reported being unable to complete all assigned showers due to workload, and the DON confirmed that residents were supposed to receive showers twice weekly per schedule and preference and acknowledged an ongoing problem with completion of showers.
EBP was not consistently implemented for residents with wounds and indwelling medical devices. An agency RN and a PA provided direct care to a resident with bilateral nephrostomy tubes without proper gown use, a resident with an indwelling catheter had the drainage bag valve/port on the floor with no EBP signage, and another resident with a g-tube reported staff had not previously worn gowns during direct care. A separate resident with a surgical wound had EBP signage on the door, but PPE was not available nearby.
A resident with an indwelling urinary catheter and multiple comorbidities, including BPH, CKD, and diabetes, was observed in bed with the catheter drainage bag partially on the floor and visible from the hallway, containing about 100 cc of yellow urine, without a dignity/privacy pouch in place. The resident was pleasantly confused about catheter privacy, and an LPN confirmed the lack of a cover and visibility of urine from the hallway. The baseline care plan noted the resident’s dependence on staff for toileting and presence of an indwelling catheter but did not address use of a dignity/privacy pouch, and the facility’s Resident Rights policy, while affirming dignity and respect, did not specifically address privacy measures for catheter drainage bags. This deficiency directly involved one resident and had the potential to affect several others with urinary catheters.
Two residents had significant medication errors. One resident received amlodipine on multiple occasions even though the MAR showed SBP readings below the ordered hold parameter, and the DON verified the errors. Another resident with a g-tube was given aspirin, atorvastatin, and brensocatib crushed together and administered through the tube by an LPN, despite no order to crush them together and no evidence that the physician or pharmacist had reviewed the safety of that method.
Food Storage Items Left Unlabeled and Undated
Penalty
Summary
Food was not appropriately labeled and dated for storage in the main kitchen. During an observation with the Dietary Manager, a bag of tortilla chips in dry storage was found open to air and not labeled or dated. In the refrigerator, an almost full pan of orange gelatin was uncovered, unlabeled, and undated, along with a bag of diced carrots and a bag of cheddar cheese that were both left open, unlabeled, and undated. In the freezer, a bag of French fries and a bag of fried chicken were both open to air and not labeled or dated. The Dietary Manager verified these findings during the kitchen tour. The facility census was 22, and the report identified one resident who received no food by mouth.
Failure to Provide Scheduled Showers and Bathing per Orders and Resident Preference
Penalty
Summary
The deficiency involves the facility’s failure to provide showers and bathing in accordance with residents’ physician orders, care plans, stated preferences, and the facility’s Hygiene, Bathing, and Showering Policy. Multiple residents who required staff assistance with activities of daily living (ADLs) did not receive scheduled showers or bed baths, and in several cases there were prolonged gaps between bathing events with little or no documentation of refusals or completed care. The facility’s own policy required that hygiene and bathing services be provided according to residents’ needs and preferences, yet records and interviews showed that this was not consistently done. One resident with metabolic encephalopathy, dementia, heart failure, and incontinence was ordered to receive showers and skin checks twice weekly on specific days per her preference. She reported that she had not been receiving her scheduled showers and could not recall the last time she had a shower or bed bath. Review of shower sheets over a two‑month period showed only two documented showers, and the EMR CNA task record showed only one shower documented, with only a single refusal noted in the progress notes. Another resident with quadriplegia and malignant neoplasm of the spinal cord, who was cognitively intact and dependent on staff for bathing and transfers, was ordered and scheduled to receive showers with skin checks twice weekly. He reported that in approximately three weeks he had only two showers, that two scheduled showers were missed because staff said they did not have time, and that his wife had to come in to provide a shower. Facility records confirmed only two showers since admission and a nine‑day period without a shower or bath, including missed scheduled shower days. A cognitively intact resident with prostate cancer, diabetes, and hypertension was ordered to receive skin checks twice weekly on bath/shower days. He and his wife reported that he had not received a bed bath since admission and that he felt dirty. There were no shower/bath sheets from admission until nine days later, and the only shower sheet present documented a refusal on a specific date but was actually completed several days after the event. Another resident with impaired cognition and functional dependence was ordered to receive skin checks twice weekly on bath/shower days; facility records showed only two bed baths during his stay and no evidence of any shower or bed bath for extended periods of 11 and 13 days, despite the DON confirming there was no medical reason he could not receive at least a bed bath. Additional residents with intact cognition and mobility limitations also did not receive showers as ordered. One resident with macular degeneration, Crohn’s disease, osteoarthritis, and a history of falls was ordered to receive showers and skin checks twice weekly and required partial to moderate assistance. Shower sheets over two months showed irregular and infrequent showers, including gaps of 10 and 14 days between showers, and the resident stated she did not get showers when she was supposed to. Another resident with a hip fracture, diabetes, congestive heart failure, and a history of falls, ordered to have showers and skin checks twice weekly, had only one documented bed bath from admission with no other shower sheets present and reported not getting enough showers. Agency CNAs reported they were unable to complete all scheduled showers and baths because there were too many assigned, and the Interim DON acknowledged that residents were to receive showers twice weekly as scheduled and per preference, verified the missing documentation and missed showers for multiple residents, and stated there had been an ongoing problem with showers getting completed.
EBP Not Implemented and Catheter Drainage Bag Contacted Floor
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were in place or implemented when indicated for residents with wounds and/or indwelling medical devices. For one resident with bilateral nephrostomy tubes, an order for EBP had been entered, but there was no signage outside the room indicating EBP. During observation, an agency RN entered the room without a gown, assessed the resident while her uniform came into direct contact with the resident, and later returned to obtain vital signs without gloves and/or a gown. A PA also assessed the resident without a gown, and her lab coat came into direct contact with the resident. The Interim DON verified both staff members should have worn EBP during direct contact care and vital sign collection. For another resident with an indwelling urinary catheter and a UTI, the catheter drainage bag was observed with part of the bag on the floor and the valve/port in direct contact with the floor. The resident also had wounds and was identified by staff as needing EBP, but there was no signage on the outside of the room indicating EBP. The resident’s baseline care plan did not include catheter care details about keeping the drainage bag and valve/port off the floor or EBP. The Interim DON verified the catheter bag should not have been on the floor and stated the resident did not have an order for EBP, despite the resident’s wounds and indwelling catheter. A resident with a g-tube had an order for EBP requiring gown and glove use during high-contact care activities. The care plan also identified EBP and included signage, PPE, and education interventions. During medication administration through the g-tube, an LPN wore a gown and gloves, which prompted the resident and the resident’s wife to question why staff had not previously used a gown during similar care. The wife stated she had seen the resident receive g-tube medications and other direct care multiple times without staff wearing a gown. Another resident with a surgical wound had an order for EBP, and although signage was present on the room door, PPE was not available on or near the door when observed. The LPN confirmed PPE for EBP was not in place.
Failure to Maintain Dignity by Not Covering Urinary Catheter Drainage Bag
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to dignity and privacy by not covering an indwelling urinary catheter drainage bag with a dignity/privacy pouch. A resident admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, chronic kidney disease, and diabetes had a physician’s order for an indwelling urinary catheter with catheter care every shift. During observation, the resident was lying in bed with the catheter drainage bag positioned at the side of the bed, with part of the bag resting on the floor. From the hallway, approximately 100 cc of yellow urine was visible in the drainage bag because it was not covered by a dignity/privacy pouch. When interviewed, the resident was pleasantly confused regarding the privacy of his catheter. An LPN confirmed that the drainage bag was not covered and that urine was visible from the hallway. Review of the resident’s baseline care plan showed that he had an indwelling catheter and was dependent on staff for toileting hygiene, but the care plan did not include any intervention to provide a dignity/privacy pouch for the catheter drainage bag. Review of the facility’s Resident Rights policy, dated 11/28/16, indicated that all residents had the right to be treated with dignity and respect, but the policy did not address ensuring privacy or dignity by covering indwelling catheter drainage bags. This issue affected one resident directly and had the potential to affect seven residents identified by the facility as having urinary catheters.
Significant Medication Errors With Blood Pressure Hold Parameters and G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, affecting two of five residents reviewed for medication administration. One resident had diagnoses including metabolic encephalopathy, acute cystitis, dementia, heart failure, anxiety disorder, delirium, and malignant neoplasm of the trachea, and had an order for amlodipine besylate 5 mg daily with instructions to hold the medication when systolic blood pressure was less than 130. Review of the MAR showed the resident received amlodipine on multiple days when the recorded systolic blood pressure was below the ordered parameter, including readings of 116, 127, 122, 121, 113, 104, 108, and 118. The DON verified these were significant medication errors and stated the medication should not have been administered outside the ordered parameters. Another resident had diagnoses including dysphagia, acute and chronic respiratory failure with hypoxia, malignant neoplasm of the tongue, and gastrostomy status. Physician orders included aspirin 81 mg chewable tablet per g-tube, atorvastatin calcium 40 mg per g-tube, and brensocatib 25 mg per g-tube, along with an order stating medications may be crushed as appropriate and placed in food or given with liquid. There was no order indicating the medications could be crushed together and administered through the g-tube, and the care plan did not address medication administration through the tube. During observation, an LPN prepared aspirin, atorvastatin, and brensocatib at the medication cart, crushed all three medications together, and administered the combined crushed medications through the resident’s g-tube after checking placement and flushing the tube with water. The LPN stated she always crushed the medications together and did not know they needed to be crushed separately unless there was a physician order. The consultant pharmacist stated she had not reviewed the medications to ensure they could be crushed together and administered safely through the g-tube, especially brensocatib, and the interim DON verified there was no evidence that the physician and/or pharmacist had reviewed whether it was safe to crush the medications together.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chagrin Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Laurels Of Chagrin Falls | 2.8 mi | ★★★★★ | 1 | 0 |
| Anna Maria Of Aurora | 5.3 mi | ★★★★★ | 12 | 0 |
| Kensington At Anna Maria | 5.3 mi | ★★★★★ | 9 | 0 |
| Ohman Family Living At Holly | 6.2 mi | ★★★★★ | 7 | 0 |
| Aurora Manor Special Care Cent | 7.3 mi | ★★★★★ | 14 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.