Inspection visit
Inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of
the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including
displaced lateral mass fracture of first cervical vertebra and fracture if the second lumbar vertebra, major
recurrent depressive disorder, repeated falls, difficulty walking, dementia and delirium.
Residents Affected - Some
Review of the comprehensive assessment (MDS 3.0) dated 02/28/19 indicated he had moderate cognitive
impairment in daily decision making ability, displayed no behaviors and required the extensive assistance
for transfers and toileting.
Review of the progress note dated 03/04/19 at 6:43 P.M. the nurse noted a physical therapy assistant and a
speech therapist found Resident #10 on the floor. His private aide was at his side. He was yelling to get the
damn lady away from him. He angrily reported the aide knocked him over.
Interview with Resident #10 on 03/25/19 at 12:42 P.M. indicated he had to wear the neck collar because he
was beat up and hit in the head. He denied his injury was from a fall. There was no evidence the resident
had an injury because of an altercation. He denied any abuse toward him by anyone.
Resident #10 was observed on 03/25/19 at 2:27 P.M., 03/26/19 at 11:08 A.M., 12:08 P.M. and 3:27 P.M. and
on 03/27/19 at 10:35 and 11:09 A.M. to have a private sitter in close proximity. He utilized a wheelchair and
wore a cervical neck collar.
Interview with the administrator on 03/27/19 at 3:58 P.M. revealed the allegation of abuse was not reported
to him. Interview with Registered Nurse (RN) #100 and the director of nursing on 03/27/19 at 4:03 P.M.
verified the allegation of abuse was not reported nor investigated. They indicated the nurse on duty was
from an agency and should have reported the allegation the facility's abuse policy and procedures should
have been implemented.
Review of the abuse policy revised December 2017 indicated reportable events include but are not limited
to when a specific written or verbal allegation asserting that resident abuse, neglect, or misappropriation of
resident property occurred. Abuse may be verbal, physical, mental or sexual. Witnessed or suspected
incidents of abuse or neglect are reported to the Abuse Coordinator and immediate supervisor. The
supervisor in charge at the time of the allegation will begin the immediate investigation. An immediate
investigation will begin and may include 1:1 interviews, pictures, statements of staff/visitors, review of
medical chart, inspection of resident environment, physician exam or hospital examination, and reporting of
results to the proper authorities. The Director of Nursing and/or nursing administration will submit
immediate reports to ODH, ensure and/or conduct a thorough investigation, and report the findings of the
investigation within 5 working days to ODH. Any staff or person suspected of abuse/neglect will be
suspended and/or removed from the building pending the result
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 11
Event ID:
366379
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza at Chagrin Falls
16695 Chillicothe Road
Chagrin Falls, OH 44023
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0607
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
of the investigation. The resident will be assured that they will be free from retribution of any kind; the
incident kept confidential and will be monitored closely.
Based on interview, review of resident records, review of three facility reported incidents for allegations of
abuse and the facility's investigations, and review of the facility's abuse policy, the facility failed to implement
their policy for abuse. This affected Resident #10 for an allegation of abuse that was never identified or
reported, Residents #87 and #93 for allegations of abuse that were not reported timely to the Ohio
Department of Health, and Residents #3, #87, and #93 for allegations of abuse that were not thoroughly
investigated. This had the potential to affect all 29 residents.
Findings include:
1. During an interview on 03/25/19 at 3:04 P.M., Resident #87 indicated an attendant here called her a liar.
The resident asked the attendant if that was what she said, and the person stated she did. Resident #87
described the attendant as a tall female, middle aged with reddish hair. She was unable to provide any
additional details. On 03/25/19 at 3:25 P.M., the allegation was reported to Registered Nurse (RN) #54.
On 03/25/19 at 5:00 P.M., an interview with the Director of Nursing (DON) and Registered Nurse (RN)
#100/Nurse Manager revealed they met with Resident #87 who repeated that staff called her a liar. She
described the staff as a tall female, middle aged. She was unable to provide any other details. RN #100
indicated she spoke with the resident's son who thought the resident may have been confused.
During an interview on 03/26/19 at 2:20 P.M., the administrator indicated he was aware of Resident #87's
concern. He spoke with RN #100, and she did not feel it was abuse. The administrator agreed the facility
did not report the allegation of abuse to the Ohio department of health (ODH). On 03/26/19 at 7:09 P.M., an
interview with the administrator revealed the facility went ahead and filed and completed a FRI today for the
allegation.
Review of the facility's Abuse, Neglect, Involuntary Seclusion, and Misappropriation Policy (reviewed
December 2017) indicated all written or verbal allegations asserting that resident abuse, neglect, or
misappropriation occurred will be reported immediately (or as soon as possible). The DON and/or nursing
administration will submit an immediate report to ODH.
2. Review of an FRI reported to ODH on 10/19/18 at 12:19 P.M. revealed Resident #93 alleged to a nurse
on 10/16/18 at approximately 1:00 A.M. that a state tested nursing assistant (STNA) hit her in the head with
a remote control. The resident was sent to the hospital later on 10/16/18. On 10/18/18 while at the hospital,
Resident #93 reported an allegation that a nurse at the nursing home was so mad she picked up the
resident's walker and threw it at her and she fell. Hospital staff reported the allegation to the facility on
[DATE].
Review of Resident #93's record revealed a progress note dated 10/16/18 at 2:42 A.M. The note
documented by RN #55 indicated at approximately 1:00 A.M., Resident #93 reported an STNA hit her in
the head with the chair remote.
Review of the facility's investigation completed 10/23/19 and the FRI revealed no evidence the 10/16/18
allegation of abuse was reported to ODH until 10/19/18 at 12:19 P.M. following a second allegation of abuse
reported to the facility by the hospital staff.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366379
If continuation sheet
Page 2 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza at Chagrin Falls
16695 Chillicothe Road
Chagrin Falls, OH 44023
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0607
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During an interview on 03/28/19 at 2:32 P.M., the DON and RN #100/Nurse Manager agreed the abuse
allegation was reported following the allegation voiced by hospital staff.
Review of the facility's Abuse, Neglect, Involuntary Seclusion, and Misappropriation Policy (reviewed
December 2017) indicated all written or verbal allegations asserting that resident abuse, neglect, or
misappropriation occurred will be reported immediately (or as soon as possible). The DON and/or nursing
administration will submit an immediate report to ODH.
3. Review of an FRI dated 10/16/18 revealed Resident #3 reported to Social Worker #41 that a six foot two
inch tall, heavy set, African-American female was verbally and mentally abusive towards him. He described
the perpetrator as an aide. The aide was going to bully him into doing things and provoke him to do things.
Resident #3 was unable to state any specifics, including date, time, name. Review of the facility's
investigation completed 10/19/18 included no resident interviews or statements. The investigation summary
indicated Resident #3 was interviewed.
Review of an FRI dated 10/19/18 revealed Resident #93 alleged an agency aide (STNA #95) hit her in the
head with a remote at approximately 1:00 A.M. on 10/16/18. The resident was sent to the hospital on
[DATE]. On 10/18/18 while hospitalized , Resident #93 alleged a nurse at the nursing home picked up her
walker and threw it at her. She then fell. Hospital staff reported the allegation to the facility on [DATE].
Review of the facility's investigation completed 10/23/18 revealed no resident interviews or statements.
Review of an FRI dated 03/26/19 revealed Resident #87 reported to the state surveyor that a tall, middle
aged, female staff called her a liar. The facility's investigation completed on 03/26/19 included an interview
with Resident #87 and no additional resident interviews or statements.
During an interview on 03/28/19 at 3:19 P.M., the DON and RN#100/Nurse Manager agreed they did not
interview or get statements from other residents during the investigations of abuse for Resident #3, #87,
and #93.
Review of the facility's Abuse, Neglect, Involuntary Seclusion, and Misappropriation Policy (reviewed
December 2017) indicated the supervisor in charge at the time of the allegation will begin the immediate
investigation. Investigations may include 1-to-1 interviews, pictures, statement from staff/visitors, review of
medical record, inspection of environment, physical exam, or hospital exam. The DON and/or nursing
administration will submit an immediate report to ODH and will ensure and/or conduct a thorough
investigation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366379
If continuation sheet
Page 3 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza at Chagrin Falls
16695 Chillicothe Road
Chagrin Falls, OH 44023
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of
the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including
displaced lateral mass fracture of first cervical vertebra and fracture of the second lumbar vertebra, major
recurrent depressive disorder, repeated falls, difficulty walking, dementia and delirium.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 02/28/19, indicated he had
moderate cognitive impairment in daily decision making ability, displayed no behaviors and required the
extensive assistance for transfers and toileting.
Review of the progress note dated 03/04/19 at 6:43 P.M. the nurse noted a physical therapy assistant and a
speech therapist found Resident #10 on the floor. His private aide was at his side. He was yelling to get the
damn lady away from him. He angrily reported the aide knocked him over.
Interview with Resident #10 on 03/25/19 at 12:42 P.M. indicated he had to wear the neck collar because he
was beat up and hit in the head. He denied his injury was from a fall. There was no evidence the resident
had an injury because of an altercation. He denied any abuse toward him by anyone.
Resident #10 was observed on 03/25/19 at 2:27 P.M., 03/26/19 at 11:08 A.M., 12:08 P.M. and 3:27 P.M. and
on 03/27/19 at 10:35 and 11:09 A.M. to have a private sitter in close proximity. He utilized a wheelchair and
wore a cervical neck collar.
Interview with the Administrator on 03/27/19 at 3:58 P.M. revealed the allegation of abuse was not reported
to him and not reported as required. Interview with RN #100 and the DON on 03/27/19 at 4:03 P.M. verified
the allegation of abuse was not reported nor investigated. They indicated the nurse on duty was from an
agency and should have reported the allegation the facility's abuse policy and procedures should have
been implemented.
Based on interview, review of resident records, observation and review of facility reported incidents (FRI)
for allegations of abuse and the facility's investigations, the facility failed to report or to timely report
allegations of abuse. This affected Resident #10 for an allegation of abuse that was never reported to the
Ohio Department of Health (ODH) and Residents #87 and #93 for allegations that were not reported timely
to ODH. The facility census was 29.
Findings include:
1. During an interview on 03/25/19 at 3:04 P.M., Resident #87 indicated an attendant here called her a liar.
The resident asked the attendant if that was what she said, and the person stated she did. Resident #87
described the attendant as a tall female, middle aged with reddish hair. She was unable to provide any
additional details. On 03/25/19 at 3:25 P.M., an interview with Registered Nurse (RN) #54 revealed
Resident #87 had never complained of how staff treat her. During the interview, the surveyor shared the
resident's concern.
On 03/25/19 at 5:00 P.M., an interview with the Director of Nursing (DON) and RN #100/Nurse Manager
revealed they met with Resident #87 who repeated that staff called her a liar. She described the staff as a
tall female, middle aged. She was unable to provide any other details. RN #100 indicated she spoke with
the resident's son who thought the resident may have been confused.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366379
If continuation sheet
Page 4 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza at Chagrin Falls
16695 Chillicothe Road
Chagrin Falls, OH 44023
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 03/26/19 at 2:20 P.M., the Administrator indicated he was aware of Resident #87's
concern. He spoke with RN #100, and she did not feel it was abuse. The Administrator agreed the facility
did not report the allegation of abuse to the ODH. On 03/26/19 at 2:28 P.M., an interview with RN
#100/Nurse Manager revealed her conversation with Resident #87's son indicated the son was not sure if
the incident really occurred.
Residents Affected - Few
Review of a FRI for Resident #87's allegation of verbal abuse revealed the facility reported it to ODH on
03/26/19 at 3:23 P.M.
During an interview on 03/26/19 at 7:09 P.M., the Administrator indicated the facility went ahead and filed
and completed a FRI today for the allegation.
2. Review of a FRI reported to ODH on 10/19/18 at 12:19 P.M. revealed Resident #93 alleged to a nurse on
10/16/18 at approximately 1:00 A.M. that a State Tested Nursing Assistant (STNA) hit her in the head with a
remote control. The resident was sent to the hospital later on 10/16/18. On 10/18/18 while at the hospital,
Resident #93 reported an allegation that a nurse at the nursing home was so mad she picked up the
resident's walker and threw it at her and she fell. Hospital staff reported the allegation to the facility on
[DATE].
Review of Resident #93's record revealed a progress note dated 10/16/18 at 2:42 A.M. The note
documented by RN #55 indicated at approximately 1:00 A.M., Resident #93 reported an STNA hit her in
the head with the chair remote. RN #55 interviewed the STNA's. STNA #57 indicated she witnessed
Agency STNA #95 hand the remote to the resident. Approximately an hour later, Resident #93 screamed,
You f .g bitch, don't you ever take my wheelchair again. It's my wheelchair.
There was no evidence the 10/16/18 allegation of abuse was reported to ODH until 10/19/18 at 12:19 P.M.
following a second allegation of abuse reported to the facility by the hospital staff.
During an interview on 03/28/19 at 2:32 P.M., the DON and RN #100/Nurse Manager agreed the abuse
allegation was reported following the allegation voiced by hospital staff on 10/18/18.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366379
If continuation sheet
Page 5 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza at Chagrin Falls
16695 Chillicothe Road
Chagrin Falls, OH 44023
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, review of facility reported incidents (FRI) for allegations of abuse, and review of the facility's
investigations, the facility failed to thoroughly investigate allegations of abuse. This affected three
(Residents #3, #87, and #93) of three residents during review of three facility reported incidents. The facility
census was 29.
Residents Affected - Few
Findings include:
1. Review of an FRI dated 10/16/18 revealed Resident #3 reported to Social Worker #41 that a six foot two
inch tall, heavy set, African-American female was verbally and mentally abusive towards him. He described
the perpetrator as an aide. The aide was going to bully him into doing things and provoke him to do things.
Resident #3 was unable to state any specifics, including date, time, name.
Review of the facility's investigation included no resident interviews or statements. The investigation
summary indicated Resident #3 was interviewed.
2. Review of an FRI dated 10/19/18 revealed Resident #93 alleged an agency aide, State Tested Nurse
Aide (STNA) #95 hit her in the head with a remote at approximately 1:00 A.M. on 10/16/18. The resident
was sent to the hospital on [DATE]. On 10/18/18 while hospitalized , Resident #93 alleged a nurse at the
nursing home picked up her walker and threw it at her. She then fell. Hospital staff reported the allegation to
the facility on [DATE].
Review of the facility's investigation of the FRI revealed no resident interviews or statements.
3. Review of an FRI dated 03/26/19 revealed Resident #87 reported to the state surveyor that a tall, middle
aged, female staff called her a liar. The FRI investigation was completed on 03/26/19 at 4:47 P.M.
Review of the facility's investigation of the FRI revealed an interview with Resident #87 and no additional
resident interviews or statements.
During an interview on 03/28/19 at 3:19 P.M., the Director of Nursing (DON) and Registered Nurse (RN)
#100/Nurse Manager agreed they did not interview or get statements from other residents during the
investigations of abuse for Resident #3, #87, and #93.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366379
If continuation sheet
Page 6 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza at Chagrin Falls
16695 Chillicothe Road
Chagrin Falls, OH 44023
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, record review and policy review, the facility failed to maintain acceptable parameters of nutritional
status by obtaining ordered daily weights and obtaining re-weights for the dietitian to have accurate data to
properly evaluate three residents (Resident's #17, #23, and #25) of four residents reviewed for nutrition and
who had sustained weight loss. The facility census was 29.
Residents Affected - Some
Findings include:
1. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] and
readmitted [DATE] with diagnoses including pneumonia, moderate chronic kidney disease, major
depressive disorder recurrent, cirrhosis of liver, diabetes with complications, cognitive communication
deficit, dysphagia, hyperlipidemia, hypercalcemia, acute and chronic respiratory failure, congestive heart
failure, paroxysmal atrial fibrillation, cerebral infarction, and gastrointestinal hemorrhage.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 01/23/19, indicated she
had moderate cognitive impairment. She was 63 inches tall and weighed 143 pounds. The MDS 3.0, dated
03/11/19, indicated she now had severe cognitive impairment and weighed 130 pounds. The assessment
indicated she had no or unknown weight loss.
The nutrition plan of care initiated on 02/27/19 indicated to obtain daily weights, monitor oral intake for
accuracy, pudding supplement daily between meals, and another nutritional supplement daily.
Review of the physician order, dated 02/26/19, indicated to obtain weight daily.
Review of the weight record revealed she weighed 129 pound on 02/26/19. No weights were obtained until
03/01/19, when she also weighed 129 pounds. She was weighed on 18 of 28 days in March 2019.
Interview with Registered Dietitian (RD) #91 on 03/27/19 at 12:40 P.M. reported there was no indication
Resident #17 refused to be weighed and verified the daily weights were not obtained as ordered to afford
an accurate assessment of her nutritional needs.
2. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] and
readmitted on [DATE]. Her diagnoses included displaced fracture of greater trochanter of left femur
subsequent encounter for closed fracture with delayed healing, cognitive communication deficit, malignant
neoplasm of the pancreas, antineoplastic chemotherapy, chondrocalcinosis, hyperlipidemia, gout,
hypothyroidism, moderate chronic kidney disease, localized edema, acute embolism and thrombosis of
deep veins of right lower extremity.
Review of the MDS 3.0, dated 02/13/19, indicated she was 63 inches tall and weighed 138 pounds. Review
of the MDS 3.0, dated 03/08/19, indicated she weighed 119 pounds and she was not on a prescribed
weight loss program.
Review of the physician order, dated 02/22/19, indicated to obtain daily weights and on 03/08/19 to obtain
weights weekly on Tuesdays and Fridays.
Review of the weight record revealed although she was ordered daily weights on 02/22/19 the first
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366379
If continuation sheet
Page 7 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza at Chagrin Falls
16695 Chillicothe Road
Chagrin Falls, OH 44023
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
weight was not obtained until 02/26/19 when she weighed 135 pounds. The next weight was not obtained
until 03/08/19 when she weighed 119 pounds. A difference of 11. 85%.
Interview with RD #91 on 03/17/19 at 12:52 P.M. indicated the resident had a 15.8% weight loss since
admission, verified weights were not obtained daily as ordered to afford an accurate assessment. RD #91
said a re-weight should be obtained with any three to four pound difference.
3. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with
diagnoses included traumatic subdural hemorrhage, repeated falls, anemia, atrial flutter, paroxysmal atrial
fibrillation, encephalopathy, cognitive communication deficit, nausea with vomiting, moderate chronic kidney
disease, atherosclerotic heart disease, hypertension, hyperlipidemia, localized edema, major depressive
disorder, cardiac pacemaker and gastro-esophageal reflux disease.
Review of the MDS 3.0, dated 03/11/19, indicated he had moderate cognitive impairment. He was 72
inches tall and weighed 156 pounds with no or unknown weight loss.
Review of the nutrition care plan initiated 02/27/19 indicated he refused nutritional supplements upon
admission but the interventions indicated to provide eight ounces of ensure clear twice daily with meals.
Review of the aide documentation revealed in the last 30 days his average intake was 50% and he was not
provided any snacks.
Review of the physician's order, dated 02/26/19, to obtain weight daily.
Review of the dietary note, dated 11/19/18, indicated he was to be weighed daily. There was only one
weight for December 2018, 19 weights for January 2019, nine weights for February 2019 and 22 weights
for March 2019. He also had weights recorded with differences above three to four pounds as evidence by
the following: 02/28/19 he weighed 166 pounds, 03/01/19 he weighed 158 pounds, 03/02/19 he weighed
160 pounds, 03/03/19 he weighed 157 pounds, 03/23/19 he weighed 154 pounds, 03/24/19 he weighed
168 pounds and on 03/25/19 he weighed 150 pounds. There was no documented evidence re-weights were
obtained.
Interview with RD #91 on 03/17/19 at 12:52 P.M. verified weights were not obtained daily as ordered to
afford an accurate assessment. RD #91 said a re-weight should be obtained with any three to four pound
difference.
Interview with State Tested Nurse Aide (STNA) #58 on 03/27/19 at 02:56 P.M. said daily weights were
obtained by the night shift. She pointed to a posted list in the nurses station titled daily weights indicating to
please do all daily weights at 6:00 A.M. All weekly weights were done on day shift. Another posting of
shower schedules revealed weights were obtained for the odd numbered rooms on Mondays and the even
numbered rooms on Tuesdays, the form was dated 11/28/18.
Interview with RN #54 on 03/27/19 at 03:10 P.M. said the aides do the weights she inputs it into the
computer. She said she notifies the Director of Nursing, Physician and Dietary Manager of weight changes.
Interview with RN #100 and the Director of Nursing on 03/27/19 at 4:10 P.M. reported the physician wanted
daily weights taken at 6:00 A.M. for residents with congestive heart failure like they do at
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366379
If continuation sheet
Page 8 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza at Chagrin Falls
16695 Chillicothe Road
Chagrin Falls, OH 44023
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
the hospital.
Level of Harm - Minimal harm
or potential for actual harm
Review of the Weight Monitoring policy and procedure, revised December 2017, revealed the charge nurse
would notify the dietitian/diet technician and primary physician of significant weight variances. Weight gains
or losses of three pounds would prompt a re-weigh of the resident. The dietitian/diet technician will review
information, assess and document follow up in the medical record within three to five business days of
notification. Weights were kept in the medical record. When recording the weight in the medical record the
nurse will review whether a significant weight variation prompted a re-weigh. If a significant gain or loss, the
resident would be placed on weekly weight schedule unless contraindicated and would be evaluated as
needed. Significant changes were as follows: 5% in one month, 7.5% in three months and 10% in six
months.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366379
If continuation sheet
Page 9 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza at Chagrin Falls
16695 Chillicothe Road
Chagrin Falls, OH 44023
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure medication administration records reflected the
amount of insulin administered. This affected one (Resident #3) of one resident with a sliding scale insulin
order of five residents reviewed for unnecessary medications. The facility had three residents with sliding
scale insulin orders. The facility census was 29.
Findings include:
Review of the record revealed Resident #3 was admitted on [DATE] with diagnoses including diabetes and
Parkinson's disease. The resident had a physician's order, dated 12/04/18, for accuchecks (blood sugar
monitoring) before meals and at bedtime with Lispro insulin coverage per sliding scale order. Humalog
insulin coverage was for blood sugar 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units,
351-400=10 units, greater than 400 notify the physician. Lispro is a fast acting insulin which begins working
in about 15 minutes.
Review of Resident #3's electronic medication administration records (eMAR's) for January, February, and
March 2019 revealed the nurses documented the blood sugar before meals and at bedtime and initialed the
medication to indicate they administered the Lispro insulin. There was no indication how much insulin the
nurse administered each time. Resident #3's blood sugars varied between 41 and 405.
During an interview on 03/27/19 at 4:27 P.M., Registered Nurse (RN) #40 (Director of Minimum Data Set)
reviewed Resident #3's eMAR for March 2019. She indicated the eMAR had the sliding scale insulin order
and documentation of the blood sugars but did not indicate how much insulin was administered. RN #40
wanted to ask one of the nurses who administers medications. In an interview on 03/27/19 at 4:32 P.M., RN
#54 agreed the eMAR did not reflect how much Lispro insulin was administered for the sliding scale insulin
order.
During an interview on 03/28/19 at 8:08 A.M., RN #40 reviewed Resident #3's eMAR's for January and
February 2019. She agreed the eMAR's did not indicate how much sliding scale insulin coverage the
nurses administered.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366379
If continuation sheet
Page 10 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366379
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eliza at Chagrin Falls
16695 Chillicothe Road
Chagrin Falls, OH 44023
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation, interview and policy review, the facility failed to ensure the kitchen environment and
service hallways were maintained in sanitary condition. This affected all 29 residents in the facility.
Residents Affected - Many
Findings include:
The initial tour of the facility on 03/25/19 began at 8:50 A.M. Three stainless steel hoods (interior sides, roof
and lip), over the cooking appliances were observed covered with grease and lint, hair and dust stuck in the
grease. The Ansul system nozzles were heavily covered in dust. The edge of the hood appeared to have
grease drips hanging on the edge directly over the cooking appliances. Interview with the Director of Dining
Services #90 on 03/25/19 at 9:00 A.M. verified the condition of the hood and said the hood and Ansul
system were cleaned every couple of months. She said it was professionally cleaned in November 2018.
The perimeter of the kitchen floor was heavily soiled with dust, dirt and debris. The gray grout in between
the tiles were black in color. Interview with the Director of Dining Services #90 on 03/25/19 at 9:10 A.M.
verified the condition of the floor said it was the responsibility of the closing cook to make sure the floors
were cleaned and mopped daily. The food was served from a servery. The food was sent to the unit prior to
each meal down a long service hallway. The floors of the service hallway were heavily soiled with dirt, dried
and loose debris. The gray grout was black in color. Interview with the Director of Dining Services #90
verified the condition of the service hallway floors and said it was the responsibility of the dish washer to
sweep and wash the service hallway floor. A subsequent visit to the kitchen on 03/25/19 at 11:15 A.M.
revealed the hoods in the same condition. Foods were being cooked on the appliances below. Interview
with the Director of Dining Services #90 on 03/25/19 at 11:15 A.M. confirmed the liquid drips on the edge of
the hood were oily when she rubbed them with her fingers.
Review of the service invoice, dated 03/2018, indicated the kitchen exhaust systems serving four hoods
cleaning included underside of hoods, filter holders, filter plenums, interior of ductwork and two fans located
on roof. This also included the cleaning of 32 baffle filters, four hoods and eight filters in each hood.
Review of the cleaning procedures for the vent hood, dated 2013, indicated daily to clean the drip pans and
weekly clean the exterior surfaces. The weekly cleaning indicated to remove filters and clean using
procedure outlined for this purpose. Spray all inside and outside surfaces with heavy duty oven cleaner. On
heavily soiled areas or where grease was baked on, loosen with brush until the grease and soil were
broken down and could be removed. Clean out the drain trough around the lower inside edge of the hood,
as well as the channels which hold the filters. Flush soil and solution with clean, hot water. Allow inside
surfaces to air dry and wipe outside surfaces dry. Polish the exterior surfaces with stainless steel polish.
Review of the master cleaning schedule #24503 indicated the exhaust hood and filters were cleaned
weekly on Thursdays, the floors were to be cleaned daily, gray rolling garbage cans every Monday, white
garbage cans every Friday, line garbage cans every Saturday.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366379
If continuation sheet
Page 11 of 11
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
10 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0351GeneralS&S Fpotential for harm
Install an approved automatic sprinkler system.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the March 28, 2019 survey of ELIZA AT CHAGRIN FALLS?
This was a inspection survey of ELIZA AT CHAGRIN FALLS on March 28, 2019. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ELIZA AT CHAGRIN FALLS on March 28, 2019?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement policies and procedures to prevent abuse, neglect, and theft."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.