Eliza at Chagrin Falls

In the surveyor’s words

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

• Actual harm, isolatedF686Mar 3, 2021

  Based on interview, record review and policy review the facility failed to ensure adequate interventions were implemented to prevent the development and deterioration of pressure ulcers. Actual Harm occurred on 01/10/21 when Resident #23, who was determined at risk for pressure ulcers on the admission assessment dated [DATE] and required two-person assist with bed mobility and transfers, did not have interventions to prevent the development of pressure ulcers or to prevent the deterioration of current pressure ulcers. The pressure ulcer to the coccyx deteriorated from a stage II (partial-thickness loss of skin with exposed dermis. […]

• No harm, potential for more than minimal, widespreadF812Jan 22, 2026

  Based on observation and staff interview, the facility failed to appropriately label and date food for storage. This had the potential to affect 21 of 22 residents who received meals from the facility kitchen. The facility identified one resident (Resident #1) who received no food by mouth. The facility census was 22.Findings include: Observations on 01/20/26 at 9:52 A.M. with Dietary Manager #239 during the initial main kitchen tour revealed the following:In dry storage there was a bag of tortilla chips open to air and not labeled or dated.In the refrigerator there was an almost full pan of orange gelatin left uncovered, unlabeled and undated, a bag of diced carrots left open, unlabeled and undated, and a bag of cheddar cheese left open, unlabeled and undated.In the freezer there was a… […]

• No harm, potential for more than minimal, widespreadF730Jun 1, 2023

  Based on record review and interview the facility failed to ensure performance reviews for nursing assistants were completed timely as required. This had the potential to affect all 11 residents residing in the facility. Findings include: Review of the personnel file for State tested Nursing Assistant (STNA) #789 revealed a hire date of 10/03/22. There was not a 90-day evaluation completed as required. Review of the personnel file for STNA #791 revealed a hire date of 05/31/22. There was not a 90-day evaluation completed as required. Review of the personnel file for STNA #798 revealed a hire date of 07/19/21. There was not a 90-day or annual evaluation completed as required. Interviews completed on 05/31/23 at 4:30 P.M. […]

• No harm, potential for more than minimal, widespreadF761Jun 1, 2023

  Based on observation and interview the facility failed to ensure all medications were stored appropriately in medication carts. This had the potential to affect all 11 residents residing in the facility. Findings include: Observation of the medication carts completed on 05/30/23 at 9:15 A.M. revealed there were a total of 23 loose medications observed. There were 13 loose medications observed in the Cherry Hill medication cart, as well as 10 loose medications and a yellow powder spilled throughout the top drawer of the Maple Lane medication cart. The facility had a total of two medication carts. Interview on 05/30/23 at 9:30 A.M. […]

• No harm, potential for more than minimal, widespreadF812Jun 1, 2023

  Based on observation and interview, the facility failed to maintain the overhead hood vents, fire suppression nozzles, and backsplash behind the stove in a clean, sanitary, and safe manner. This had the potential to affect ten of the eleven residents residing in the facility. Resident #76 did not receive food from the facility kitchen. The facility census was 11. Findings include: A tour of the kitchen on 05/30/23 from 9:15 A.M. through 9:44 A.M. with Dietary Manager #821 revealed the overhead vents and the fire suppression nozzles were greasy and had accumulated dust. The backsplash behind the stovetop was greasy. Dietary Manager #821 verified the condition of the hood, nozzles, and back splash at the time of the observation.