Cycle 1
Health 2023-06-01 · Fire 2023-06-01
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Chagrin Falls, OH
Eliza At Chagrin Falls
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
16695 Chillicothe Road, Chagrin Falls, OH
(440) 543-4221
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
29
Certified beds
Average residents
23
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2009-10-24
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.12
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.72
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
5.24
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.84
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.72
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.87
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.08
CMS adjusted RN staffing hours
Adjusted total hours
5.06
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,303
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.84
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.97% · Performance 22.11% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.25
Baseline 5.71% · Performance 5.97% · Measure score 6.25 · Achievement 6.25 · Improvement 0
Total nurse turnover
0
Baseline 71.43% · Performance 70.00% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.53% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 211 · Observed rate 10.9% · Lower 95% interval 8.13% |
| Discharge to community | 63.13% |
50.57%
12.6 pts better
|
Better than the National Rate · Eligible stays 210 · Observed rate 59.52% · Lower 95% interval 56.77% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 95.92% |
95.27%
0.7 pts better
|
Numerator 94 · Denominator 98 |
| Falls with major injury | 1.02% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 98 |
| Discharge self-care score | 25.93% |
53.69%
27.8 pts worse
|
Numerator 21 · Denominator 81 |
| Discharge mobility score | 34.57% |
50.94%
16.4 pts worse
|
Numerator 28 · Denominator 81 |
| Pressure ulcers or injuries, new or worsened | 1.02% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 98 · Adjusted rate 1.21% |
| Healthcare-associated infections requiring hospitalization | 5.97% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 4.08% · Lower 95% interval 3.49% |
| Staff COVID-19 vaccination coverage | 11.43% |
8.2%
3.2 pts better
|
Numerator 4 · Denominator 35 |
| Staff flu vaccination coverage | 10.87% |
42%
31.1 pts worse
|
Numerator 5 · Denominator 46 |
| Discharge function score | 32.1% |
56.45%
24.4 pts worse
|
Numerator 26 · Denominator 81 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 72 · Denominator 72 |
| Resident COVID-19 vaccinations up to date | 22.64% |
25.2%
2.6 pts worse
|
Numerator 12 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.6% |
3.3%
5.3 pts worse
|
3.3%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 27.6% |
26.1%
1.5 pts worse
|
11.4%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.6% |
| Percentage of long-stay residents who lose too much weight | 21.2% |
6.2%
15 pts worse
|
5.4%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.3% |
25.4%
7.9 pts worse
|
19.6%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.0% |
11.5%
4.5 pts worse
|
16.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.0% |
6.2%
22.8 pts worse
|
14.9%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.4% |
0.2%
5.2 pts worse
|
1.0%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with pressure ulcers | 24.6% |
3.7%
20.9 pts worse
|
5.1%
19.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
78.1%
16.6 pts better
|
81.7%
13 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.2% · Q2 93.9% · Q3 93.8% · Q4 96.8% · 4Q avg 94.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.7% |
12.5%
3.2 pts worse
|
12.0%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 14.3% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
75.6%
16.1 pts better
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
25.1%
1.1 pts better
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 21.4% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-04-29 · Fire 2021-04-29
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2019-03-28 · Fire 2019-03-28
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-12-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-21
F · Potential for more than minimal harm
2023-06-01
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-23
F · Potential for more than minimal harm
2023-06-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-23
F · Potential for more than minimal harm
2023-06-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-23
F · Potential for more than minimal harm
2023-06-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-23
F · Potential for more than minimal harm
2023-06-01
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-06-23
F · Potential for more than minimal harm
2023-06-01
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-06-23
E · Potential for more than minimal harm
2023-06-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-23
F · Potential for more than minimal harm
2021-04-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-05-28
E · Potential for more than minimal harm
2021-04-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-05-28
F · Potential for more than minimal harm
2019-03-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-05-10
F · Potential for more than minimal harm
2019-03-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-05-10
F · Potential for more than minimal harm
2019-03-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-05-10
E · Potential for more than minimal harm
2019-03-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-05-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-02-13
F · Potential for more than minimal harm
2023-06-01
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-06-23
F · Potential for more than minimal harm
2023-06-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-06-01
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-06-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-06-01
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-06-23
C · Minimal harm
2023-06-01
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-06-16
F · Potential for more than minimal harm
2021-04-29
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-05-28
F · Potential for more than minimal harm
2021-04-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-04-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-28
F · Potential for more than minimal harm
2019-03-28
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2019-05-10
E · Potential for more than minimal harm
2019-03-28
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-05-10
E · Potential for more than minimal harm
2019-03-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-05-10
D · Potential for more than minimal harm
2019-03-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-05-10
D · Potential for more than minimal harm
2019-03-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-05-10
D · Potential for more than minimal harm
2019-03-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-05-10
Penalties and ownership
What sits behind the stars
Ownership
Boyson, Richard
Corporate Director · Individual
Boyson, Richard
Corporate Officer · Individual
Boyson, Richard
W-2 Managing Employee · Individual
Fletcher, Richard
Corporate Director · Individual
Fodor, Alayne
Corporate Director · Individual
Fox, Richard
Corporate Director · Individual
Gray, Michael
Corporate Director · Individual
Gray, Michael
Corporate Officer · Individual
Griveas, Jennifer
Corporate Officer · Individual
Hartney, Margaret
Corporate Director · Individual
Hernandez, Kimberly
Corporate Officer · Individual
Krassen, Glenn
Corporate Director · Individual
Messina, Michele
Corporate Director · Individual
Rogerson, James
Corporate Director · Individual
Scanlon, Patricia
Corporate Director · Individual
Sereda, Sheryl
Corporate Director · Individual
Shields, Kathleen
Corporate Officer · Individual
Shrock, Terrie
Corporate Director · Individual
Stoner, John
Corporate Director · Individual
Tracy, Allen
Corporate Director · Individual
Weigle, Fred
Corporate Director · Individual
Weitzel, Margaret
Corporate Director · Individual
Young, Hilton
Corporate Director · Individual
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#3
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