12
Inspections on file
9
Deficiencies cited
7
Visits with none
0
Substandard care
0
Immediate jeopardy

The most recent inspection on file for Meadow Falls of Rocky River took place on February 4, 2026. Across the 12 inspections published by the Ohio Department of Health, surveyors cited 9 deficiencies.

A deficiency is a rule the surveyor found the facility was not meeting. Ohio inspects against two rule books at once, so most findings carry a federal code and an Ohio code for the same problem; each is counted once here, the way the state counts it. Correction dates are the state's confirmation that the issue was fixed.

This report reproduces what Ohio publishes and nothing else. Of the 12 inspections listed, the state publishes the surveyor's written findings for 5; for the other 7 it publishes only the date, the type of visit and the number of deficiencies - 7 of which found none.

Facility Details

Ohio license number
#2233R
County
Cuyahoga
Administrator
Christa Decker
Director of nursing
Diana Shores
Phone
(440) 356-2282
Ownership
For Profit - Individual

Inspections

12 on file · 9 deficiencies
February 4, 2026Complaint survey1 deficiency
R-0712Adequate and appropriate treatment and careOhio citation
What the surveyor found

Based on medical record review, facility policy review, and interview, the facility failed to ensure adequate care and services to prevent falls for Resident #14 who had a fall during a staff assisted transfer and a fall during a staff assisted shower and for Resident #111 who had a fall during a caregiver assisted shower. This affected two Residents (#14 and #111) of three reviewed for falls. The facility census was 106.

Findings include:

1. Review of the medical record for Resident #14 revealed an admission date of 07/14/22 and diagnoses including vascular dementia with behavioral disturbance, unsteadiness on feet, abnormalities of gait and mobility, generalized anxiety disorder, repeated falls, dizziness and giddiness, and osteoarthritis.

Review of the service plan for falls dated 07/20/22 revealed Resident #14 would be encouraged to call for assistance and have frequent safety checks for falls. An intervention of gait belt for all transfers was added on 11/27/25.

Review of Resident Assistant (RA) care card for October 2025 revealed Resident #14 required one staff assistance for showers and two staff assistance with transfers.

Review of Resident Level of Care Assessment dated 10/07/25 revealed Resident #14 was oriented to person. It was noted Resident #14 had occasional disruptive, aggressive or socially inappropriate behaviors but was easily redirected. Resident #14 had altered gait and was able to use wheelchair and a walker. Resident #14 required extensive assistance for transfers. Resident #14 required total assistance for bathing and preferred showers.

Review of Morse fall assessment dated 10/07/25 revealed Resident #14 was at high risk for falls.

Review of the alert note dated 10/24/25 at 10:38 A.M. revealed Resident #14 was in the shower room receiving a shower assisted by facility staff. It was noted Resident #14 became combative and pulled on the RA. Resident #14 slipped and fell off the shower chair and hit her head. Resident #14 sustained a hematoma on the left eyebrow. A range of motion assessment was completed with no findings.

Review of witnessed fall incident report dated 10/24/25 revealed RA #808 was providing a shower to Resident #14. Resident #14 became combative and was pulling on RA #808. Resident #14 fell off the shower chair and hit her head. There was no evidence documented RA #808 had called for help when Resident #14 became combative.

Review of health status note dated 10/28/25 at 3:54 P.M. revealed a fall follow up was completed and it was noted Resident #14 had bruising around left eye. It was newly noted Resident #14's right arm was swollen and painful to the touch. The physician was notified and ordered an X-ray of the right arm, hand, and knee and Tramadol 50 milligrams three times per day for 14 days.

Review of X-ray result dated 10/28/25 revealed an acute transverse fracture through the midsection of the radius with minimal anterior displacement and soft tissue swelling over the forearm.

Review of communication with physician note dated 10/29/25 at 8:01 A.M. revealed Resident #14's X-ray results showed acute transverse fracture through diaphysis of the radius with minimal anterior displacement and soft tissue swelling. The physician gave order to send to hospital for evaluation.

Review of Major Injury Investigation Form dated 10/31/25 revealed Resident #14 was getting a shower assisted by facility staff, became combative and slipped off the shower chair. It was noted Resident #14 was grabbing and pulling on RA #808 causing her to slip off shower chair. The report noted Resident #14 was often combative with care. Resident #14 had hematoma to left eyebrow and fracture of right radius. Resident #14 was sent to the hospital for evaluation and returned with temporary cast to right arm. A fall intervention was added to medicate Resident #14 with as needed Seroquel 25 milligrams 30 minutes prior to showers. There was no evidence documented RA #808 called for assistance when Resident #14 became combative.

Review of incident note dated 11/26/25 at 5:27 P.M. revealed Licensed Practical Nurse (LPN) #803 was attempting to assist Resident #14 in transfer from a recliner chair to wheelchair. The note stated Resident #14 was unable to complete the transfer and fell. Resident #14 sustained a bruise on the forehead and was medicated for pain with Tylenol.

Review of health status note dated 11/27/25 at 10:30 A.M. revealed Resident #14's son and daughter had concerns about the fall on 11/26/25 and wanted to send Resident #14 to the hospital for evaluation. It was noted Resident #14's son stated I'm not trying to be mean, but you guys just need to stop dropping my mom she is 95. Resident #14's daughter requested use of gait belt for all transfers. Resident #14 was sent to the hospital for further evaluation per family request.

Review of the facility fall investigation for Resident #14's fall on 11/26/25 revealed LPN #803 attempted to transfer Resident #14 from a recliner to a wheelchair. Both LPN #803 and Resident #14 fell during the transfer. The Executive Director (ED) and Director of Nursing (DON) reviewed common area camera footage and observed the fall. It was reported LPN #803 used improper techniques while transferring Resident #14 resulting in fall. Facility staff including LPN #803 were educated on proper transfer techniques.

Review of Performance Deficiency Notification dated 12/02/25 revealed LPN #803 was disciplined for using improper transfer techniques resulting in a fall.

Interview on 02/03/26 at 8:02 A.M. with Executive Director (ED) confirmed on 11/26/25 when LPN #803 did not use proper technique to transfer Resident #14 resulting in a fall.

Interview on 02/03/26 at 8:27 A.M. with LPN #803 revealed on 11/26/25 she was helping the RAs move residents into the dining room for lunch. LPN #803 stated Resident #14 was in a recliner chair and LPN #803 attempted to transfer to the wheelchair. LPN #803 stated Resident #14 was in front of her and the wheelchair was behind them. LPN #803 stated she stood up Resident #14 on her own and began to turn when they both stumbled to the floor. LPN #803 stated she was unsure of Resident #14's transfer needs at time of fall and had not looked at the RA care card prior to transferring Resident #14.

Follow up interview on 02/03/26 at 11:55 A.M. with ED revealed they no longer had access to the camera footage for review of Resident #14's fall on 11/26/25.

Interview on 02/03/26 at 12:58 P.M. with RA #808 revealed on 10/23/25 she was providing Resident #14 a shower in the central shower room. RA #808 stated Resident #14 did not like the water on her and was moving around quiet a bit. RA #808 stated Resident #14 was in the shower chair and became combative. RA #808 stated Resident #14 was swinging her arms and trying to reach out to RA #808 when she fell to the floor. RA #808 stated Resident #14 had broken her arm during the fall.

2. Review of the closed medical record for Resident #111 revealed an admission date of 08/04/22 and discharge date of 10/24/25. Diagnoses included dementia with agitation, osteoarthritis, repeated falls, mild cognitive impairment, restless legs syndrome, and anxiety disorder.

Review of the service plan for falls dated 08/08/22 revealed Resident #111 would be encouraged to call for assistance and have frequent safety checks for falls.

Review of Resident Assistant (RA) care card for October 2025 revealed Resident #111 required one staff assistance for showers. There was no indication of transfer assistance needs.

Review of Resident Level of Care Assessment dated 10/10/25 revealed Resident #111 was oriented to person and situation. It was noted Resident #111 was frequently disoriented and may require repeated verbal prompts and direction. Resident #111 did not have any noted behaviors. Resident #111 required extensive hands-on assistance by staff for ambulation. Resident #111 required extensive staff assistance for transfers and bathing. It was noted Resident #111 preferred showers. Resident #111 was on hospice services.

Review of Morse fall assessment dated 10/10/25 revealed Resident #111 had high risk for falling.

Review of witnessed fall incident report dated 10/23/25 at 12:00 P.M. revealed Resident #111 was receiving a shower from Hospice Aide #816. Resident #111 became combative with care and Hospice Aide #816 stated she lowered Resident #111 to the floor. There was no noted pain at time and Resident #111 was assisted into the wheelchair. Resident #111 later complained of left knee discomfort and was assessed by Hospice Nurse #815. A left leg X-ray was ordered and Resident #111 was medicated for pain. There was visible internal rotation noted. There was no evidence documented hospice aide called for assistance when Resident #111 became combative.

Review of health status note dated 10/23/25 at 12:20 P.M. revealed hospice gave order to continue pain management with Morphine every two hours and Lorazepam as ordered. If breakthrough pain Resident #111 could be medicated with Tramadol and Acetaminophen as ordered.

Review of incident note dated 10/23/25 at 1:42 P.M. revealed Resident #111 was receiving a shower from Hospice Aide #816. Resident #111 became combative with care and was lowered to the floor. Resident #111 was transferred into a wheelchair then into bed and started complaining of left leg discomfort. There was no evidence documented hospice aide called for assistance when Resident #111 became combative.

Review of witness statement dated 10/23/25 for Hospice Aide #816 revealed Resident #111 was taken to the bathroom for a shower. Resident #111 stood up and was being assisted to turn and sit on the shower chair. Resident #111 began to resist sitting on the chair and Hospice Aide #816 had to lower her to the floor while Resident #111 continued to resist. Hospice Aide #816 then called for assistance from the facility nurse to get Resident #111 off the floor and proceeded to give Resident #111 a bed bath.

Review of X-ray result dated 10/23/25 revealed Resident #111 had acute displaced fracture of the distal femur. It was noted Resident #111's bones were osteopenic.

Review of health status note dated 10/24/25 at 12:23 P.M. revealed Hospice Nurse #815 came to the facility to visit Resident #111. Hospice Nurse #815 reported the physician wanted to send Resident #111 to the emergency room for evaluation and for possible realignment of left leg with an immobilizer. Hospice Nurse #815 was awaiting approval from Resident #111's power of attorney (POA).

Review of incident note dated 10/24/25 at 1:23 P.M. revealed Resident #111 was transferred to the hospital.

Review of Major Injury Investigation Form dated 10/27/25 revealed Resident #111 had witnessed fall with Hospice Aide #816 while receiving a shower. Resident #111 sustained a left femur fracture. Hospice Aide #816 reported Resident #111 was combative with care. It was noted combativeness was normal for Resident #111. Resident #111 was transferred to the hospital for evaluation and pain management per hospice order. Resident #111's POA opted for nonsurgical intervention and moved Resident #111 to a hospice facility for end-of-life care. There was no evidence documented hospice aide called for assistance when Resident #111 became combative.

Interview on 02/03/26 at 8:02 A.M. with Executive Director (ED) confirmed Resident #111 had a fall during a shower while being assisted by Hospice Aide #816.

Interview on 02/03/26 at 9:32 A.M. with Licensed Practical Nurse (LPN) #804 revealed Resident #111 was receiving a shower from Hospice Aide #816 on 10/24/25. LPN #804 stated Resident #111 became combative with care and Hospice Aide #816 lowered her to the floor. LPN #804 stated Resident #111 was yelling and resisting. LPN #804 stated they were able to get Resident #111 into bed and Hospice Aide #816 completed a bed bath. LPN #804 stated Hospice Aide #816 did not request assistance when Resident #111 became combative.

Interview on 02/04/26 at 8:55 A.M. with Hospice Nurse #815 revealed she had evaluated Resident #111 following the fall on 10/24/25. Hospice Nurse #815 stated Resident #111 was crying in pain and her leg was internally rotated at the knee. Hospice Nurse #815 indicated if a resident was being resistive or combative with care it was expected the staff member stop what doing and make sure the resident was safe.

Review of facility policy Transfer Policy undated revealed the resident's service plan should be reviewed to determine the type of transfer assistance required. It was recommended to always wear a safety gait belt when assisting residents. It was important to be aware of a resident's cognitive ability and impact on transfer communication abilities.

Review of facility policy Falls and Falls Risk Management Policy undated revealed cognitive impairment may contribute to falls.

This violation represents non-compliance investigated under Master Complaint Number OH00169156 and Complaint Numbers OH00169109 and OH00168970.

Rule
Ohio Administrative Code - residential care rules
October 16, 2025Licensure survey1 deficiency
R-0559Procure, store, prepare, distribute and serve foodsOhio citation
What the surveyor found

Based on observation, interview, and facility policy review, the facility failed to maintain a clean and sanitary kitchen area and prevent cross contamination while handling food. This had the potential to affect all residents residing in the facility who received food from the facility kitchen. The facility identified no residents on a nothing by mouth (NPO) diet. The facility census was 109.

Findings include:

Observation on 10/15/25 at 10:40 A.M. of the facility main kitchen revealed dust build up on ceiling above three compartment sink and dish machine area. There was significant buildup of food debris and dust on top of the dish machine and parts under the machine. There was buildup of food debris and crumbs on the storage racks under the steam table line. The kitchen hood had a coating of built-up grease with dust stuck to the grease. The convection oven had significant grease buildup on windows. There were crumbs, grease, and dust on the outside of the convection oven. The outside of the reach in cooler adjacent to the steam table revealed dust build up. The floors throughout the kitchen had dark smears of an unidentified substance with slippery spots. The standing mat in front of the steam table was dark with grease buildup and food debris.

Observation on 10/15/25 at 11:00 A.M. of the lunch tray line revealed lunch was a roast beef sandwich with au jus dip, German potato salad, and cucumber salad with fruit cup dessert. Cook #804 and #885 were observed to serve trays for delivery in Styrofoam to-go containers. The resident's tray ticket was taped to the top of the container and as Cooks #804 and #885 served lunch, the ticket was observed to hang down into the food in the steam table across all three steam wells. Observed Cook #804 prepare alternative items including sandwiches, hamburgers, hot dogs. Cook #804 used same knife to cut all food items in half. There was a cooler for sandwich toppings including lettuce, tomatoes, and cheese. Cook #804 used his gloved hands to rip bacon in half for a bacon, lettuce, and tomato sandwich then get lettuce and tomato from cooler without changing gloves or using utensils. This occurred throughout the meal service for sandwiches. Observed Dietary Aide #805 wearing a pair of gloves. Dietary Aide #805 placed gloved hand on the floor and got onto knees to get a pitcher lid from under a prep table. Dietary Aide #805 then stood up, grabbed the pitcher with lid, and washed it in the three compartment sink with steel wool. Dietary Aide #805 then ran the pitcher through dish machine and started preparing iced tea. Dietary Aid #805 filled pitcher with iced tea then was observed to leave kitchen to serve to residents. Dietary Aide #805 did not change gloves or wash hands during entire observation. Additionally, throughout tray line observation, Dietary Aide #805 was observed rubbing gloved hands on her clothing and continuing to deliver ready-to-eat food to residents. Dietary Aide #805 was also observed scraping plates of finished food into the trash can while wearing gloves then continuing to serve other residents without washing hands or changing gloves.

Observation on 10/15/25 at 12:40 P.M. with Dietary Manager (DM) #908 revealed a walk-in freezer which was located outside. The floor of the freezer had significant debris around and under storage racks. There was a pile of ice buildup on the floor of the freezer, ice hanging down from the condenser, and drips of ice onto food storage rack and food boxes.

Interview on 10/15/25 at 12:54 P.M. with DM #908 confirmed all of the above findings. DM #908 reported she was new and was still having some issues with the existing staff following sanitation guidelines and her rules for the kitchen. DM #908 indicated she had educated all the staff on many of the issues identified.

Review of facility policy General Sanitation of Kitchen undated revealed food and nutrition services staff would maintain the sanitation of the kitchen through compliance with cleaning schedule.

Review of facility policy Employee Sanitary Practices undated revealed gloves were a single use item and should be discarded after each use. Hands must be washed prior to and after removing gloves.

Review of facility policy Bare Hand Contact with Food and Use of Plastic Gloves undated revealed gloved hands were considered a food contact surface that can become contaminated or soiled. Gloves may be used for a single task and discarded when damaged, soiled, or disruptions occur in operation. Gloves would be considered contaminated when handling soiled trays or dishes, picking up items from floor, during food preparation to prevent cross contamination when changing tasks.

Rule
Ohio Administrative Code - residential care rules
July 17, 2025Complaint survey1 deficiency
R-0564Kitchen and dining areas clean and sanitary; transporting meals; garbageOhio citation · correction confirmed 10/16/2025
What the surveyor found

Based on interviews, pest control work invoices, and personnel file review, the facility failed to maintain a sanitary kitchen resulting in a roach infestation. This had the potential to affect all 111 residents residing in the facility.

Findings include:

Interview on 07/17/25 at 8:15 A.M. with Dietary Aide (DA) #201, DA #202 and DA #203 revealed they observed roaches in the kitchen for months. Each DA stated the pest control company had been out several times to spray and treat the kitchen areas.

Interview of 07/17/25 at 9:20 A.M. with the Executive Director (ED) revealed the facility had a dietary director who was terminated recently due to many concerns including food preparations, diets served as ordered, and the cleanliness of the kitchen. The ED stated the former dietary director was given a performance improvement plan dated 06/02/25 and time to correct the concerns. The dietary director failed to complete tasks written in the performance improvement plan and was terminated on 06/10/25.

Review of the pest control work invoices indicated the facility received monthly pest control services including preventative maintenance in the kitchen. The invoices indicated no roach activity was noted until 05/15/15. The invoice dated 05/15/25 timed 4:11 P.M. indicated the kitchen was messy and staff needed to put in more effort related to maintaining a sanitary kitchen. The invoice also indicated staff wanted the pest control company to just spray the chemicals without any other interventions. The pest control technician provided education indicating the product would need time to work and the kitchen needed to be cleaned.

Review of the performance improvement plan for Dietary Director #200 dated 06/02/25 revealed concerns including cleanliness of the main kitchen, the ice scooper was not in a covered container, sitting on a dirty ice machine, open items in the main kitchen freezer were not dated or in a sealed container.

Review of the pest control service invoice dated 06/04/25 timed 2:23 P.M. revealed roaches found behind deep freezer and large stand-up cooler in kitchen. The kitchen was baited and treated heavily. Observations noted a lot of food debris around and this was causing the problem to worsen. The invoice indicated to please clean and de-grease areas.

Review of the performance deficiency notification dated 06/10/25 revealed Dietary Director #200 failed to complete tasks as listed in the improvement plan and was terminated on 06/10/25.

Review of the pest control service invoice dated 06/27/25 timed 5:56 P.M. revealed a high infection of roaches by dishwasher and cooler in kitchen.

Review of the pest control service invoice dated 07/09/25 timed 8:09 A.M. revealed the kitchen was treated, roaches were at a minimum, observed one roach.

Review of the pest control service invoice dated 07/14/25 timed 6:55 P.M. noted no roach activity was observed.

Interview on 07/17/25 at 11:02 A.M. with DA #201 revealed DA #201 had a picture dated 07/17/25 timed 11:09 A.M. of a roach located on a table in the main dining room. Observation of the picture confirmed a picture of a roach on a dining room table.

Interview on 07/17/25 at 11:05 A.M. with DA#204 revealed she observed a roach running across the floor within the last hour.

Review of the facility policy titled Sanitization

Rule
Ohio Administrative Code - residential care rules
May 7, 2025Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies
No deficiencies cited
Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.
March 21, 2025Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies
No deficiencies cited
Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.
December 7, 2024Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies
No deficiencies cited
Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.
April 10, 2024Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies
No deficiencies cited
Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.
December 21, 2023Complaint survey2 deficiencies
R-0138Professional standardsOhio citation · correction confirmed 10/16/2025
What the surveyor found

Based on observation, medical record review, policy review and staff interviews, the facility failed to administer

medications according to professional standards and ensure medications were available for administration.

This affected seven (#13, #14, #15, #16, #17, #18, and #19) of seven residents observed for medication administration. The facility census was 108.

Findings include:

1. Record review for Resident #13 revealed an admission date of 04/01/17. Diagnoses included dementia, moderate with mood disturbances, major depressive disorder, anxiety disorder, and somatoform disorder (a mental health condition that causes an individual to experience physical bodily symptoms in response to psychological distress).

Record review of the Service Plan for Resident #13 dated 11/15/21 revealed Resident #13 needed physical assistants with administration of medication.

Record review of the assessment for Brief Interview for Mental Status (BIMS), completed 12/03/23, revealed Resident #13 was moderately impaired.

Record review of the physician orders for Resident #13 revealed on 12/03/23, Resident #13 received new orders for divalproex sodium delayed release 250 milligrams (mg), give 250 mg by mouth two times a day for behavioral disturbances.

Record review of the Medication Administration Record (MAR) for December 2023 revealed Resident #13 was to receive the divalproex sodium delayed release 250 mg every morning (QAM) and every night (QHS). Record review revealed Resident #13 did not receive the divalproex sodium delayed release 250 mg doses on 12/03/23 QHS, 12/04/23 QAM and QHS, 12/05/23 QAM and QHS, 12/06/23 QAM and QHS and 12/07/23 QAM.

Record review of the progress notes for 12/03/23 through 12/07/23 at 3:00 P.M., revealed Resident #13's daughter or physician was not notified Resident #13 did not have her divalproex sodium delayed release 250 mg available for administration.

Interview on 12/21/23 between 11:45 A.M. and 12:03 P.M., with Director of Nursing (DON) and Licensed Practical Nurse (LPN) #201 revealed Resident #13's daughter provided the medications for Resident #13 and the nurses administered the medications. DON and LPN #201 revealed nurses were to notify Resident #13's daughter prior to medications running out and or if the medication was not available. DON and LPN #201 confirmed Resident #13 did not receive the physician ordered medication, divalproex sodium delayed release 250 mg doses on 12/03/23 QHS, 12/04/23 QAM and QHS, 12/05/23 QAM and QHS, 12/06/23 QAM and QHS and 12/07/23 QAM. DON and LPN #201 confirmed Resident #13's daughter nor the physician was notified the medication divalproex sodium was not available for administration prior to 12/07/23.

2. Record review for Resident #14 revealed an admission date of 06/24/22. Diagnoses included dementia, vitamin D deficiency, cardiomyopathy, chronic atrial fibrillation, and presence of cardiac defibrillator.

Record review of the Service Plan for Resident #14 dated 06/28/22 revealed Resident #14 needed help with medications due to cognitive loss.

Record review of the BIMS for Resident #14 dated 12/03/23 revealed Resident #14 was cognitively intact.

Record review of the December 2023 monthly physician orders for Resident #14 revealed an order for aspirin 81 mg, give one tablet two times a day related to chronic atrial fibrillation. Resident #14 also had an order for ergocalciferol (vitamin D) 1.25 mg, give one tablet by mouth every morning every Monday and Thursday for supplement.

Observation on 12/21/23 at 9:11 A.M., revealed LPN #202 was walking up the hall in the residential area with four cups of medications stacked on each other in her left hand. LPN #202 revealed these cups with multiple medications in each cup were for Residents #15, #17, #18, and #19. LPN #202 revealed this was how she did it, she had to be done passing the residents medication by 11:00 A.M. LPN #202 stated she would prepare several resident's medications at once, put their room number on the medication cup, stack the cups on top each other, leaving the medication cart behind with the residents list of medications, and would go deliver the preset medications to each resident. Observation revealed LPN #202 took the medications to Residents #15, #17, #18, and #19 for administration.

Observation during medication administration on 12/21/23 at 9:30 A.M., with LPN #202 revealed Resident #14 did not have aspirin 81 mg or vitamin D 1.25. mgs available for administration. LPN #202 verified the medications were not available for administration. LPN #202 revealed this happened all the time, many nurses did not reorder resident medications from the pharmacy timely then they were not available for administration.

3. Record review for Resident #15 revealed an admission date of 10/27/18. Diagnosis included anxiety disorder.

Record review of the Service Plan for Resident #15 dated 11/15/21 revealed Resident #15 needed help with medications due to cognitive loss.

Record review of the BIMS for Resident #15 dated 09/19/23 revealed Resident #15 had moderate cognitive impairment.

Record review of the December 2023 monthly physician orders for Resident #15 revealed an order for Ativan 0.5 mg by mouth in the morning for anxiety.

Record review of the MAR revealed Resident #15 did not receive the Ativan as ordered on 12/06/23.

Observation during medication administration on 12/21/23 at 9:40 A.M., with LPN #202 revealed Resident #15 did not have Ativan 0.5 mg available for administration. LPN #202 verified the medications were not available for administration due to nurses not reordering the medications timely.

4. Record review for Resident #16 revealed an admission date of 02/13/23. Diagnoses included unspecified dementia moderate with agitation and osteoarthritis.

Record review of the Service Plan for Resident #16 dated 02/13/23 revealed Resident #16 needed help with medications due to cognitive loss.

Record review of the BIMS for Resident #16 dated 12/02/23 revealed Resident #16 had severe cognitive impairment.

Record review of the December 2023 monthly physician orders for Resident #16 revealed an order for lidocaine external patch 4% apply to right hip topically in the morning for pain related to displaced fracture of the base of the neck of the right femur. Resident #16 also had an order for Depakote delayed release 125 mg, give three capsules by mouth two times a day related to unspecified dementia with behavioral disturbances. Resident #16 also had an order for senna plus 8.5-50 mg give one tablet by mouth two times a day for constipation. Resident #16 had an order for Miralax oral powder 17 grams per scoop, give one scoop by mouth in the morning for constipation.

Record review of the medication administration record for Resident #16 revealed the resident did not receive the lidocaine external patch on 12/06/23, 12/13/23, 12/20/23 or 12/21/23. Record review revealed Resident #16 did not receive the senna plus on 12/01/23 QAM and QHS, 12/04/23 QAM, 12/09/23 QAM, 12/10/23 QAM, 12/13/23 QAM, 12/14/23 QAM, 12/15/23 QAM and QHS, 12/18/23 QAM, 12/19/23 QAM and QHS, 12/20/23 QAM and 12/21/23 QAM. Resident #16 also did not receive Miralax oral powder 17 grams on 12/01/23, 12/04/23, 12/09/23, 12/10/23 12/14/23, 12/15/23, 12/18/23, 12/19/23, or 12/21/23.

Observation during medication administration on 12/21/23 at 9:45 A.M., with Med Tech #203 revealed Resident #16 did not have lidocaine patches 4% available, senna 8.6-50 mg or Depakote 125 mg available for administration. Med Tech #203 confirmed Resident #16 was also to receive Miralax 17 grams and stated she was not going to offer it because she knew he didn't like it and wouldn't drink it.

Interview at the time of observation, with Med Tech #203, confirmed medications were not reordered timely for administration and Resident #16 would not receive the medications today because the pharmacy wouldn't deliver them until the following day.

Interview on 12/21/23 between 12:03 P.M. and 3:22 P.M., with DON and Administrator revealed nurses should never preset medications. Administrator and DON confirmed it was the facility responsibility to notify the families seven to 10 days in advance of medications running out if the family delivered the medications. If the pharmacy delivered the medication, it was also the facility responsibility to assure medications were reordered timely and delivered timely for administration.

Review of the undated policy titled, Medication Administration Policy

Rule
Ohio Administrative Code - residential care rules
R-0339Administered meds - given only to and as prescribedOhio citation · correction confirmed 10/16/2025
What the surveyor found

Based on observation, medical record review, review of policy, and staff interviews, the facility failed to administer medications as ordered by the physician. This affected four (#13, #14, #15, and #16) of seven residents reviewed for medication administration. The facility census was 108.

Findings include:

1. Record review for Resident #13 revealed an admission date of 04/01/17. Diagnoses included dementia, moderate with mood disturbances, major depressive disorder, anxiety disorder, and somatoform disorder (a mental health condition that causes an individual to experience physical bodily symptoms in response to psychological distress).

Record review of the Service Plan for Resident #13 dated 11/15/21 revealed Resident #13 needed physical assistants with administration of medication.

Record review of the assessment for Brief Interview for Mental Status (BIMS), completed 12/03/23, revealed Resident #13 was moderately impaired.

Record review of the physician orders for Resident #13 revealed on 12/03/23, Resident #13 received new orders for divalproex sodium delayed release 250 milligrams (mg), give 250 mg by mouth two times a day for behavioral disturbances.

Record review of the Medication Administration Record (MAR) for December 2023 revealed Resident #13 was to receive the divalproex sodium delayed release 250 mg every morning (QAM) and every night (QHS). Record review revealed Resident #13 did not receive the divalproex sodium delayed release 250 mg doses on 12/03/23 QHS, 12/04/23 QAM and QHS, 12/05/23 QAM and QHS, 12/06/23 QAM and QHS and 12/07/23 QAM.

Record review of the progress notes for 12/03/23 through 12/07/23 at 3:00 P.M., revealed Resident #13's daughter or physician was not notified Resident #13 did not have her divalproex sodium delayed release 250 mg available for administration.

Interview on 12/21/23 between 11:45 A.M. and 12:03 P.M., with Director of Nursing (DON) and Licensed Practical Nurse (LPN) #201 revealed Resident #13's daughter provided the medications for Resident #13 and the nurses administered the medications. DON and LPN #201 revealed nurses were to notify Resident #13's daughter prior to medications running out and or if the medication was not available. DON and LPN #201 confirmed Resident #13 did not receive the physician ordered medication, divalproex sodium delayed release 250 mg doses on 12/03/23 QHS, 12/04/23 QAM and QHS, 12/05/23 QAM and QHS, 12/06/23 QAM and QHS and 12/07/23 QAM. DON and LPN #201 confirmed Resident #13's daughter nor the physician was notified the medication divalproex sodium was not available for administration prior to 12/07/23.

2. Record review for Resident #14 revealed an admission date of 06/24/22. Diagnoses included dementia, vitamin D deficiency, cardiomyopathy, chronic atrial fibrillation, and presence of cardiac defibrillator.

Record review of the Service Plan for Resident #14 dated 06/28/22 revealed Resident #14 needed help with medications due to cognitive loss.

Record review of the BIMS for Resident #14 dated 12/03/23 revealed Resident #14 was cognitively intact.

Record review of the December 2023 monthly physician orders for Resident #14 revealed an order for aspirin 81 mg, give one tablet two times a day related to chronic atrial fibrillation. Resident #14 also had an order for ergocalciferol (vitamin D) 1.25 mg, give one tablet by mouth every morning every Monday and Thursday for supplement.

Observation during medication administration on 12/21/23 at 9:30 A.M., with LPN #202 revealed Resident #14 did not have aspirin 81 mg or vitamin D 1.25. mgs available for administration. LPN #202 verified the medications were not available for administration. LPN #202 revealed this happened all the time, many nurses did not reorder resident medications from the pharmacy timely then they were not available for administration.

3. Record review for Resident #15 revealed an admission date of 10/27/18. Diagnosis included anxiety disorder.

Record review of the Service Plan for Resident #15 dated 11/15/21 revealed Resident #15 needed help with medications due to cognitive loss.

Record review of the BIMS for Resident #15 dated 09/19/23 revealed Resident #15 had moderate cognitive impairment.

Record review of the December 2023 monthly physician orders for Resident #15 revealed an order for Ativan 0.5 mg by mouth in the morning for anxiety.

Record review of the MAR revealed Resident #15 did not receive the Ativan as ordered on 12/06/23.

Observation during medication administration on 12/21/23 at 9:40 A.M., with LPN #202 revealed Resident #15 did not have Ativan 0.5 mg available for administration. LPN #202 verified the medications were not available for administration due to nurses not reordering the medications timely.

4. Record review for Resident #16 revealed an admission date of 02/13/23. Diagnoses included unspecified dementia moderate with agitation and osteoarthritis.

Record review of the Service Plan for Resident #16 dated 02/13/23 revealed Resident #16 needed help with medications due to cognitive loss.

Record review of the BIMS for Resident #16 dated 12/02/23 revealed Resident #16 had severe cognitive impairment.

Record review of the December 2023 monthly physician orders for Resident #16 revealed an order for lidocaine external patch 4% apply to right hip topically in the morning for pain related to displaced fracture of the base of the neck of the right femur. Resident #16 also had an order for Depakote delayed release 125 mg, give three capsules by mouth two times a day related to unspecified dementia with behavioral disturbances. Resident #16 also had an order for senna plus 8.5-50 mg give one tablet by mouth two times a day for constipation. Resident #16 had an order for Miralax oral powder 17 grams per scoop, give one scoop by mouth in the morning for constipation.

Record review of the medication administration record for Resident #16 revealed the resident did not receive the lidocaine external patch on 12/06/23, 12/13/23, 12/20/23 or 12/21/23. Record review revealed Resident #16 did not receive the senna plus on 12/01/23 QAM and QHS, 12/04/23 QAM, 12/09/23 QAM, 12/10/23 QAM, 12/13/23 QAM, 12/14/23 QAM, 12/15/23 QAM and QHS, 12/18/23 QAM, 12/19/23 QAM and QHS, 12/20/23 QAM and 12/21/23 QAM. Resident #16 also did not receive Miralax oral powder 17 grams on 12/01/23, 12/04/23, 12/09/23, 12/10/23 12/14/23, 12/15/23, 12/18/23, 12/19/23, or 12/21/23.

Observation during medication administration on 12/21/23 at 9:45 A.M., with Med Tech #203 revealed Resident #16 did not have lidocaine patches 4% available, senna 8.6-50 mg or Depakote 125 mg available for administration. Med Tech #203 confirmed Resident #16 was also to receive Miralax 17 grams and stated she was not going to offer it because she knew he didn't like it and wouldn't drink it.

Interview at the time of observation, with Med Tech #203, confirmed medications were not reordered timely for administration and Resident #16 would not receive the medications today because the pharmacy wouldn't deliver them until the following day.

Interview on 12/21/23 between 12:03 P.M. and 3:22 P.M., with DON and Administrator revealed it was the facility responsibility to notify the families seven to 10 days in advance of medications running out if the family delivered the medications. If the pharmacy delivered the medication, it was also the facility responsibility to assure medications were reordered timely and delivered timely for administration.

Review of the undated policy titled, Medication Administration Policy

Rule
Ohio Administrative Code - residential care rules
August 25, 2023Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies
No deficiencies cited
Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.
August 3, 2023Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies
No deficiencies cited
Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.
March 3, 2023Complaint survey · listed in Ohio's index; no findings report publishedNo deficiencies
No deficiencies cited
Ohio lists this visit in its inspection index with no deficiencies. The state publishes a findings report only when a visit cites something, so there is no further detail to show.
September 8, 2022Licensure survey4 deficiencies
R-0127Types of allowed personal care services trainingOhio citation · correction confirmed 10/16/2025
What the surveyor found

Based on record review and interview the facility failed to ensure resident care assistants received required training on interpersonal, observational and communication skills or had competency training upon hire. This had the potential to affect all 93 residents residing in the facility.

Findings include:

Review of the personnel file for Resident Assistant (RA) #206 with a hire date of 10/01/21 revealed there was no documented training on interpersonal, observational and communication skills provided by a licensed nurse as required or had competency training upon hire.

Review of the personnel file for RA #207 with a hire date of 04/19/22 revealed there was no documented training on interpersonal, observational and communication skills provided by a licensed nurse as required or had competency training upon hire.

Review of the personnel file for RA #205 with a hire date of 07/01/22 revealed there was no documented training on interpersonal, observational and communication skills provided by a licensed nurse as required or had competency training upon hire.

On 09/08/22 at 1:01 P.M. interview with Human Resources Director (HRD) #204 verified RA #205, #206 and #207 had no documented training on interpersonal, observational and communication skills by a licensed nurse or competency training as required. HRD #204 confirmed RA #205, #206 and #207 received had only received training from their peers upon hire.

This violation substantiates Complaint Number OH00135299.

Rule
Ohio Administrative Code - residential care rules
R-0140Background check requiredOhio citation · correction confirmed 10/16/2025
What the surveyor found

Based on record review and interview the facility failed to ensure all direct care employees were checked through the State Nurse Aide Registry (NAR) for a finding of resident abuse, neglect, and misappropriation of property prior to or on the first day of work. This had the potential to affect all 93 residents residing in the facility.

Findings include:

Review of the personnel file for Resident Assistant (RA) #206 with a hire date of 10/01/21 revealed there was no documented evidence RA #206 was checked through the State NAR prior to or on the first day of work as required.

Review of the personnel file for RA #207 with a hire date of 04/19/22 revealed there was no documented evidence RA #207 was checked through the State NAR prior to or on the first day of work as required.

Review of the personnel file for Licensed Practical Nurse (LPN) #208 with a hire date of 06/12/22 revealed there was no documented evidence LPN #208 was checked through the State NAR prior to or on the first day of work as required.

Review of the personnel file for RA #205 with a hire date of 07/01/22 revealed there was no documented evidence RA #205 was checked through the State NAR prior to or on the first day of work as required.

On 09/08/22 at 11:04 A.M. interview with Human Resources Director #204 verified LPN #208 and Resident Assistants #205, #206 and #207 were not checked through the State NAR for a finding of resident abuse, neglect, and misappropriation of property prior to or on the first day of work as required.

This violation substantiates Complaint Number OH00135299.

Rule
Ohio Administrative Code - residential care rules
R-0561Menu Planning; record keepingOhio citation · correction confirmed 10/16/2025
What the surveyor found

Based on record review and interview the facility failed to maintain a record of food substitutions from the menu for at least three months as required. This had the potential to affect all 93 residents residing in the facility.

Findings include:

On 09/08/22 at 11:03 A.M. record review with Dietary Director #201 of the facility food substitution log revealed there was no record of when food was substituted from the menu over the past three months.

Interview with Dietary Director #201 at the time of the review revealed the facility had made food substitutions from the menu in the last three months but had not kept a food substitution log for at least three months as required.

Rule
Ohio Administrative Code - residential care rules
R-0614Notify director when normal business interruption due to emergency/disasterOhio citation · correction confirmed 10/16/2025
What the surveyor found

Based on record review and interview the facility failed to conduct at least twelve (12) fire exit drills, one on each shift at least every three months to familiarize staff members and residents with signals, evacuation procedures and emergency action required under varied times and conditions. The facility also failed to transmit a fire signal and verify receipt of that signal within twelve hours after conducting silent alarm fire drills. This had the potential to affect all 93 residents residing in the facility.

Findings include:

Review of the facility fire drill records revealed night shift fire drills were conducted on 10/15/21, 02/11/22, 05/20/22 and 08/19/22.

On 09/08/22 at 10:06 A.M. interview with Maintenance Director #200 verified fire drills were not conducted during the night shift at least once every three months as required.

In addition, review of the fire drill records revealed the night shift fire drills were conducted at 5:00 A.M. on 10/15/21, 02/11/22, 05/20/22, and 08/19/22. The drills were all silent drills with no alarm activated. There was no evidence the facility transmitted a fire signal and verified the receipt of the signal within twelve hours after conducting the silent alarm on 10/15/21, 02/11/22, 05/20/22 and 08/19/22.

On 09/08/22 at 10:06 A.M. interview with Maintenance Director #200 verified there was no evidence the facility transmitted a fire signal and verified the receipt of the signal within twelve hours after conducting the silent alarm on 10/15/21, 02/11/22, 05/20/22 and 08/19/22.

Rule
Ohio Administrative Code - residential care rules