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
Inspections
12 on file · 9 deficienciesFebruary 4, 2026Complaint survey1 deficiency▼
R-0712Adequate and appropriate treatment and care▼
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.
October 16, 2025Licensure survey1 deficiency▼
R-0559Procure, store, prepare, distribute and serve foods▼
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.
July 17, 2025Complaint survey1 deficiency▼
R-0564Kitchen and dining areas clean and sanitary; transporting meals; garbage▼
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