Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 The Laurels Of Chagrin Falls during CMS and state inspections, most recent first.
A CNA with a recent conviction for domestic violence, a disqualifying offense under state law, continued to provide direct care to all residents after the conviction. Facility leadership was aware of the conviction but allowed the CNA to work, citing personal character standards, despite not meeting the required time elapsed since probation discharge. This action was not in compliance with state regulations or facility policy.
Two residents who required staff assistance with bathing did not consistently receive or were not documented as being offered scheduled baths/showers. One resident with significant medical needs and mild cognitive impairment missed several scheduled bathing opportunities without documentation, while another resident, who sometimes refused care, also experienced missed or undocumented bathing assistance. Facility leadership confirmed the lack of documentation and the residents' need for physical help or reminders.
The facility failed to conduct quarterly care conferences for two residents, one with moderate cognitive impairment and another with severe cognitive impairment, as required by policy. The oversight was discovered through an audit, revealing missed conferences in 2024 without documented reasons.
A resident with multiple pressure ulcers did not receive wound care as ordered by the physician. The RN Wound Nurse failed to cleanse the resident's bilateral heels with normal saline and pat them dry before applying dressings, contrary to the physician's orders and the facility's Clean Dressing Change policy. This was confirmed by a Regional RN during an observation.
A facility failed to provide a resident's prescribed nutritional supplement, ice cream, during a meal, despite it being ordered to address weight loss. The resident, with Alzheimer's and heart disease, was slightly underweight and had a regular diet with supplements. An observation showed the ice cream was missing from the meal tray, and a nutrition associate was unsure why it was not included, contrary to the facility's policy on nutritional supplementation.
An LPN administered expired Humalog insulin to a resident using a Kwikpen that was first used over 28 days ago. The LPN confirmed the pen was expired and should have been discarded according to the manufacturer's instructions.
A long-term care facility failed to properly clean a glucometer, risking cross-contamination of bloodborne pathogens, and did not adhere to hand hygiene protocols during catheter care. An LPN used an ineffective cleaning method for the glucometer, and a CNA did not change gloves between soiled and clean tasks, contrary to CDC guidelines. These deficiencies were observed in residents with conditions such as diabetes and urinary retention.
The facility failed to follow the prescribed menu for two residents on a pureed diet, serving incorrect portion sizes of pureed meals. The CDM, who was not usually responsible for serving, acknowledged the under-serving and lack of oversight due to a staff absence.
Failure to Remove CNA Convicted of Disqualifying Offense
Penalty
Summary
The facility failed to ensure that a Certified Nurse Aide (CNA) who had been convicted of a disqualifying offense, specifically first-degree misdemeanor domestic violence, did not continue to provide direct care to residents. Personnel records, background check logs, and court documents confirmed that the CNA was arrested and later convicted of domestic violence. Despite this conviction, which is listed as a disqualifying offense under Ohio Administrative Code, the CNA continued to work in the facility and provide direct care to residents. The review of staff schedules showed that the CNA worked multiple shifts after the conviction date, while still on probation for the offense. Interviews with the Human Resources Director and the interim Administrator revealed that both were aware of the conviction but allowed the CNA to continue employment, citing the use of personal character standards. However, the CNA did not meet the specific requirement that at least five years must have elapsed since being fully discharged from probation for an offense of violence, as outlined in the relevant state regulations. Facility policy and the staff handbook clearly state that conviction of a relevant criminal offense may result in termination, and that staff are responsible for reporting such convictions. The facility's own documentation and interviews confirmed that the CNA's continued employment was not in compliance with state law or facility policy, as the CNA had access to all residents during this period despite the disqualifying conviction.
Failure to Provide and Document Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide sufficient bathing assistance to residents who were dependent on staff for activities of daily living (ADL), specifically bathing and showering. For one resident with multiple complex medical conditions, including infection, sepsis, COPD, diabetes, and cognitive impairment, documentation showed that scheduled baths/showers were not offered or recorded on several occasions. The resident required at least some physical assistance or reminders from staff to complete bathing, but there was no documentation to confirm that these were provided on the missed dates. The Director of Nursing (DON) and Administrator confirmed the lack of documentation and the resident's need for assistance. Another resident, who was cognitively intact but required physical assistance with bathing due to various medical and psychiatric diagnoses, also had multiple missed or undocumented scheduled baths/showers. This resident reported not being offered a bath/shower when needed or desired, despite sometimes refusing care or preferring to wash at the sink. The DON and Administrator acknowledged that the resident often refused care but stated that documentation should exist for each scheduled bath/shower, whether completed or refused. The absence of such documentation for both residents was confirmed during interviews.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were completed quarterly for two residents, resulting in a deficiency. Resident #14, who was admitted with chronic obstructive pulmonary disease, malignant neoplasm of the prostate, paranoid schizophrenia, and unspecified dementia, had a moderate cognitive impairment as indicated by a BIMS score of 9 out of 15. Despite the requirement for quarterly care conferences, the documentation showed that Resident #14 only had care conferences on two occasions in 2024, with no evidence of a conference in the last quarter. The progress notes from March 2024 to February 2025 did not provide any explanation for the missed care conference. Similarly, Resident #13, who was admitted with unspecified dementia, senile degeneration of the brain, chronic diastolic congestive failure, and unspecified protein-calorie malnutrition, had a severe cognitive impairment with a BIMS score of 3 out of 15. This resident required maximal assistance with daily activities. The care conference documentation revealed that a quarterly care conference was missed in November 2024, which was only discovered after an audit. The facility's policy mandates that interdisciplinary care conferences be held quarterly, among other occasions, but this was not adhered to for these residents.
Failure to Follow Wound Care Orders for Resident
Penalty
Summary
The facility failed to ensure that a resident's pressure ulcer wound care was completed as ordered. The resident, who was admitted with diagnoses including senile degeneration of the brain, essential hypertension, and major depressive disorder, had multiple pressure ulcers requiring specific wound care treatments. Physician orders specified cleansing the wounds with normal saline, patting them dry, applying betadine, and covering them with an ABD pad and Kerlix every night shift. However, during an observation of the wound care process, it was noted that the RN Wound Nurse did not cleanse the resident's bilateral heels with normal saline and pat them dry before applying the dressings, as per the physician's orders. The resident's medical record and skin and wound evaluation forms indicated the presence of several pressure wounds, including an unstageable left heel pressure wound, a right ankle deep tissue injury, a stage three right middle heel pressure ulcer, and a right lateral forefoot deep tissue injury. Despite the detailed care plan and physician orders, the wound care procedure observed did not adhere to the prescribed protocol, as confirmed by a Regional RN. The facility's Clean Dressing Change policy also outlined the necessary steps for wound care, which were not followed during the observed procedure.
Failure to Implement Nutritional Supplement as Planned
Penalty
Summary
The facility failed to ensure that a resident's nutritional supplement was implemented as planned. The resident, who was admitted with diagnoses including Alzheimer's disease, hypertensive heart disease with heart failure, and mild cognitive impairment, was slightly underweight and had been prescribed a regular diet with between meal supplements for nutritional support. Despite the dietary progress note indicating that the resident's regular diet was tolerated and that snacks were available in the resident's room, the resident's lunch meal ticket included an order for ice cream to address weight loss, which was not provided during the observed meal. During an observation, the resident was served a meal consisting of turkey, stuffing, green bean casserole, a roll, pumpkin pie, and grape juice, but the ice cream, which was part of the standing orders for weight loss, was missing. An interview with a nutrition associate revealed uncertainty as to why the ice cream was not included on the resident's tray, despite it being listed on the meal ticket. The facility's Nutritional Supplementation policy, which was revised in October, stated that supplements should be provided when clinically necessary to maintain weight, health, and hydration, indicating a failure to adhere to this policy in the resident's case.
Expired Insulin Not Discarded
Penalty
Summary
The facility failed to ensure that a resident's expired insulin was discarded appropriately. During an observation, an LPN administered three units of Humalog fast-acting insulin to a resident using a Humalog Kwikpen, which was marked with a date indicating it was first used more than 28 days prior. The LPN confirmed that the insulin pen was expired and should have been discarded after 28 days of use. According to the Humalog KwikPen Instructions for Use, the pen should be stored at room temperature and discarded after 28 days, even if insulin remains in the pen.
Infection Control and Hand Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of the blood glucose testing (BGT) machine, leading to potential cross-contamination of bloodborne pathogens. An LPN was observed using a 70 percent alcohol prep pad to clean the glucometer after testing the blood glucose levels of two residents. The facility's policy required the use of an EPA-approved disinfectant effective against HIV, Hepatitis C, and Hepatitis B viruses, which 70 percent ethanol solutions are not. The LPN admitted to not using bleach wipes due to their unavailability on the medication cart, which was confirmed by a registered nurse. Additionally, the facility did not adhere to proper hand hygiene and glove use during catheter care for a resident. A CNA was observed performing catheter and perineal care without changing gloves between tasks, using the same soapy water for washing and rinsing, and completing the procedure with soiled gloves. The CNA admitted to being unaware of the need to change gloves between soiled and clean tasks, which is contrary to CDC guidelines that recommend changing gloves when moving from a soiled body site to a clean site. The deficiencies were observed during the care of residents with various medical conditions, including diabetes, dementia, and urinary retention. The facility's failure to follow proper infection control protocols and hand hygiene practices posed a risk of infection and cross-contamination among residents, as evidenced by the observations and interviews conducted during the survey.
Failure to Follow Prescribed Pureed Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on a pureed diet, specifically affecting two residents. The menu for the day specified certain portion sizes for pureed meals, including sloppy joes, tater tots, lima beans, soup, and a cookie. However, during the lunch tray service, the portions served did not match the menu specifications. The Certified Dietary Manager (CDM) was observed using a #16-scoop, which is two ounces, to serve the pureed sloppy joe meat and beans, while the tater tots were served with a spatula, resulting in unknown portion sizes. This discrepancy was noted for both residents receiving pureed diets, with one resident receiving double portions that still did not meet the required amounts. The CDM acknowledged the under-serving of pureed beans and tater tots, confirming that the portions did not meet the four-ounce serving sizes as outlined in the diet spreadsheet. The CDM admitted to not having the spreadsheet available during meal preparation, which contributed to the oversight. Additionally, the CDM was not typically responsible for serving at the trayline but had to step in due to a staff member's absence, which further impacted the ability to provide proper oversight during meal service. This deficiency was identified during an investigation under a specific complaint number.
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What surveyors actually found near you
We read the 1,143 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Eliza At Chagrin Falls | 2.8 mi | ★★★★★ | 7 | 0 |
| Solon Pointe At Emerald Ridge | 5.4 mi | ★★★★★ | 21 | 0 |
| Ahc Of Landerhaven Llc | 6.3 mi | ★★★★★ | 1 | 0 |
| Anna Maria Of Aurora | 6.4 mi | ★★★★★ | 12 | 0 |
| Kensington At Anna Maria | 6.5 mi | ★★★★★ | 9 | 0 |
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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.