Symphony at Mentor — Ohio Facility Report

Inspections on file

Deficiencies cited

Visits with none

Substandard care

Immediate jeopardy

The most recent inspection on file for Symphony at Mentor took place on January 7, 2026. Across the 12 inspections published by the Ohio Department of Health, surveyors cited 10 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 6; for the other 6 it publishes only the date, the type of visit and the number of deficiencies - 6 of which found none.

Facility Details

Ohio license number

#2346R

County

Lake

Administrator

Robin Irons

Director of nursing

Nicia Noble

Phone

(440) 256-8320

Ownership

For Profit - Corporation

Inspections

12 on file · 10 deficiencies

January 7, 2026Complaint 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.

October 31, 2025Licensure survey3 deficiencies▼

R-0615Fire drill requirementsOhio citation · correction confirmed 02/02/2026▼

What the surveyor found

Based on record review, interview, and facility policy review, the facility failed to conduct evening shift fire drills at least once every three months. This had the potential to affect all 43 residents residing in the facility. Findings include: Review of the fire safety binder on 10/21/25 with the Maintenance Manager (MM) #123 revealed evening shift fire drills completed on 11/19/24 at 6:00 P.M. and 06/27/25 at 3:18 P.M. There were no evening shift fire drills conducted between 11/19/24 and 06/27/25. Interview on 10/21/25 at 11:17 A.M. with the MM #123 verified there were no evening shift fire drills conducted between 11/19/24 and 06/27/25. Interview on 10/22/25 at 2:00 P.M. with the Executive Director verified the evening fire drills were not conducted at least once every three months. Review of the facility policy titled, Fire Drill ProcedureBased on record review, interview, and facility policy review, the facility failed to conduct evening shift fire drills at least once every three months. This had the potential to affect all 43 residents residing in the facility.

Findings include:

Review of the fire safety binder on 10/21/25 with the Maintenance Manager (MM) #123 revealed evening shift fire drills completed on 11/19/24 at 6:00 P.M. and 06/27/25 at 3:18 P.M. There were no evening shift fire drills conducted between 11/19/24 and 06/27/25.

Interview on 10/21/25 at 11:17 A.M. with the MM #123 verified there were no evening shift fire drills conducted between 11/19/24 and 06/27/25.

Interview on 10/22/25 at 2:00 P.M. with the Executive Director verified the evening fire drills were not conducted at least once every three months.

Review of the facility policy titled, Fire Drill Procedure

Rule

Ohio Administrative Code - residential care rules

R-0660Maintain heating, electrical, bldg services; central heating check Q2 yearsOhio citation · correction confirmed 02/02/2026▼

What the surveyor found

Based on record review and interview, the facility failed to complete a central heating inspection within the past two years. This had the potential to affect all 43 residents residing in the facility.

Findings include:

Review of the facility maintenance records on 10/21/25 with the Maintenance Manager (MM) #123 revealed there was no central heating inspection completed within the past two years.

Interviews on 10/21/25 at 11:17 A.M. and 3:03 P.M. with MM #123 verified there was no central heating inspection completed over the past two years.

Interview on 10/22/25 at 2:00 P.M. with the Executive Director verified the central heating inspection was not completed over the past two years.

Rule

Ohio Administrative Code - residential care rules

R-0711Free from abuseOhio citation · correction confirmed 02/02/2026▼

What the surveyor found

Based on closed medical record review, review of a facility self-reported incident and investigation, policy review and interview, the facility failed to protect Resident #44's right to be free from physical abuse by Resident #13. This affected one resident (#44) of six residents reviewed for abuse. The facility census was 43. Actual harm occurred on 02/26/25 when Resident #44, who had severe cognitive impairment, was pushed to the ground by Resident #13 during an altercation which resulted in hospitalization for treatment of spinal fractures. The resident was unable to return to baseline due to failure to thrive from multiple skeletal fractures and dementia. Findings include: Review of the closed medical record for Resident #44 revealed an admission date of 09/18/24 with diagnoses including dementia without behavioral disturbance, anxiety, Sjogren syndrome, Barrett's esophagus, gastro-esophageal reflux disease (GERD), and osteoporosis without current pathological fracture. Review of the Mini Mental State Examination (MMSE) dated 09/18/24 revealed Resident #44 had a score of one which indicated the resident had severe cognitive impairment. Review of Resident #44's service plan dated 11/07/24 revealed the need for staff to provide support during episodes of disruptive behavior. Review of the resident's progress notes from 09/18/24 through 02/26/25 revealed Resident #44 had behaviors including anger, anxiety, smearing of feces, wandering into other resident rooms, crying, wandering on the unit, and yelling. Redirection and medication management were documented to be frequently ineffective. Review of a progress note dated 02/26/25 revealed Resident #44 was observed on the floor against the wall in the hallway. The resident complained of back pain but there was no bruising, redness or swelling noted. Resident #44 was transported to the hospital by emergency services. Staff reported when the resident was found, there was another resident (Resident #13) who stood over her and said, I will push you down again like I just did. Review of a progress note dated 03/01/25 revealed Resident #44 remained in the hospital and per paperwork, had acute compression fractures to spine. Review of a facility self-reported incident (SRI) #257627 dated 02/26/25 revealed staff heard a loud thud and Resident #44 screaming from the back hallway. When staff arrived at the scene, Resident #44 was on the ground with Resident #13 standing over Resident #44. The staff reported Resident #13 said, I will push you again like I just didBased on closed medical record review, review of a facility self-reported incident and investigation, policy review and interview, the facility failed to protect Resident #44's right to be free from physical abuse by Resident #13. This affected one resident (#44) of six residents reviewed for abuse. The facility census was 43.

Actual harm occurred on 02/26/25 when Resident #44, who had severe cognitive impairment, was pushed to the ground by Resident #13 during an altercation which resulted in hospitalization for treatment of spinal fractures. The resident was unable to return to baseline due to failure to thrive from multiple skeletal fractures and dementia.

Findings include:

Review of the closed medical record for Resident #44 revealed an admission date of 09/18/24 with diagnoses including dementia without behavioral disturbance, anxiety, Sjogren syndrome, Barrett's esophagus, gastro-esophageal reflux disease (GERD), and osteoporosis without current pathological fracture.

Review of the Mini Mental State Examination (MMSE) dated 09/18/24 revealed Resident #44 had a score of one which indicated the resident had severe cognitive impairment.

Review of Resident #44's service plan dated 11/07/24 revealed the need for staff to provide support during episodes of disruptive behavior.

Review of the resident's progress notes from 09/18/24 through 02/26/25 revealed Resident #44 had behaviors including anger, anxiety, smearing of feces, wandering into other resident rooms, crying, wandering on the unit, and yelling. Redirection and medication management were documented to be frequently ineffective.

Review of a progress note dated 02/26/25 revealed Resident #44 was observed on the floor against the wall in the hallway. The resident complained of back pain but there was no bruising, redness or swelling noted. Resident #44 was transported to the hospital by emergency services. Staff reported when the resident was found, there was another resident (Resident #13) who stood over her and said, I will push you down again like I just did.

Review of a progress note dated 03/01/25 revealed Resident #44 remained in the hospital and per paperwork, had acute compression fractures to spine.

Review of a facility self-reported incident (SRI) #257627 dated 02/26/25 revealed staff heard a loud thud and Resident #44 screaming from the back hallway. When staff arrived at the scene, Resident #44 was on the ground with Resident #13 standing over Resident #44. The staff reported Resident #13 said, I will push you again like I just did

Rule

Ohio Administrative Code - residential care rules

April 22, 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 23, 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.

November 27, 2024Licensure survey3 deficiencies▼

R-0615Fire drill requirementsOhio citation · correction confirmed 12/23/2024▼

What the surveyor found

Based on record review and interview, the facility failed to conduct fire drills on each shift at least every three months, ensure confirmation of transmission of the fire alarm signal with verification of receipt of signal within twelve hours after coded announcement, and residents capable of self- evacuation were evacuated to safe areas within the building. This affected all residents. Current census was 42 residents.

Findings include:

Review of the facility's fire drills on 11/27/24 at 1:15 P.M. revealed fire drills were not conducted during day shift during the third quarter, the night shift during second and fourth quarters, and no fire drills were conducted in the month of April 2024 on any shift. Review of the fire drills conducted in the last year revealed no residents were evacuated. Silent alarms conducted on 12/22/23, 05/02/24, 06/30/24, 10/31/24, and 11/19/24 did not show confirmation of transmission with verification of signal within twelve hours of the coded announcement.

Interview on 11/27/24 at 1:30 P.M. with the Facilities Manager, confirmed the absence of any fire drill in the month of April. Additionally, the Facilities Manager confirmed the absence of quarterly drills for day and night shifts and the confirmation of transmission and verification of signal within twelve hours.

Rule

Ohio Administrative Code - residential care rules

R-0616Disaster drill requirementsOhio citation · correction confirmed 12/23/2024▼

What the surveyor found

Based on record review and interview, the facility failed to conduct a tornado drill during the months of March through July. This affected all residents. Current census was 42 residents.

Findings include:

Review of the facility's disaster drills on 11/27/24 at 1:20 P.M. revealed the absence of a tornado drill during the months of March through July.

Interview on 11/27/24 at 1:30 P.M. with the Facilities Manager confirmed the absence of any tornado drills being completed

Rule

Ohio Administrative Code - residential care rules

R-0625Monthly fire inspectionsOhio citation · correction confirmed 12/23/2024▼

What the surveyor found

Based on record review and interview, the facility failed to complete monthly fire safety inspections within the past year. This affected all residents at the facility. Current census was 42 residents.

Findings include:

Record review on 11/27/24 at 1:20 P.M. noted an absence of any monthly fire safety inspection reports for the past year.

Interview conducted on 11/27/24 at 1:30 P.M. with the Facilities Director confirmed the absence of any monthly fire safety inspections. The Facilities Director was not aware of the regulation requirement and did not have the Ohio Department of Health Inspection Form.

Rule

Ohio Administrative Code - residential care rules

September 20, 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.

July 5, 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.

November 7, 2023Complaint survey1 deficiency▼

R-0645Resident-activated call systemOhio citation▼

What the surveyor found

Based on interview, observation, and record review the facility failed to ensure each resident had a resident- activated call system in good working order that, at minimum, provided for the transmission of calls from resident rooms and toilet. This affected all four Residents (#16, #19, #26 and #37) of four residents reviewed for functional call light system and had the potential to affect all 37 residents residing in the facility.

Findings included:

1. Review of medical record for Resident #16 revealed an admission date of 02/13/23 and diagnoses included dementia, hypertension and atrial fibrillation. There was no documentation in her medical record regarding being assessed for the ability to utilize her call light.

2. Review of medical record for Resident #19 revealed an admission date of 07/06/21 and diagnoses included Alzheimer's dementia, osteopenia, and degenerative joint disease. There was no documentation in her medical record regarding being assessed for the ability to utilize her call light.

3. Review of medical record for Resident #26 revealed an admission date of 09/29/22 and diagnoses included moderate dementia, hypertension, and hyperlipidemia. There was no documentation in her medical record regarding being assessed for the ability to utilize her call light.

4. Review of medical record for Resident # 37 revealed an admission date of 01/24/23 and diagnoses included dementia, depression, and anxiety. There was no documentation in her medical record regarding being assessed for the ability to utilize her call light.

Environmental tour was conducted on 11/07/23 between 7:58 A.M. and 9:00 A.M. revealed no call light system was being utilized.

Interview on 11/07/23 between 8:13 A.M. and 9:10 A.M. with Caregiver #602, Caregiver #603, Med Tech #604 and Med Tech # 605 verified the call light system was not being used.

Interview on 11/07/23 with Resident #19 verified the call lights did not work. Resident #19 verified she pressed the button and it had lit up but no one came so she did not think it worked.

Interview on 11/07/23 at 9:28 A.M. with Clinical Specialist (CS) # 607 verified the facility did not use the call light system because the residents had memory impairment. CS #607 explained because the residents had memory impairment they did checks on the residents instead of having a call light system. CS #607 reported she did not know how long the call light system was not functioning in the facility. When asked how often the staff check on the residents if there was no call light system functioning for the residents, CS #607 said there were no specific times set for the staff to do checks on the residents.

Interview on 11/07/23 at 11:45 A.M. with Maintenance Director (MD) and Med Tech #605 verified the call light system was not being used. MD #601 reported it had not worked from March to June of 2023 then a new hard drive was put in. The MD stated he then removed the call light system about a week ago when he remodeled the room it was in, because no one was using it.

Interview on 11/07/23 at 1:45 P.M. with Operations Specialist #606 and CS #607 verified the facility did not assess residents to see if they can use the call light or not and do not have a policy on how often the staff checked on the Residents.

This violation represents non-compliance investigated under Complaint Number OH00148038

Rule

Ohio Administrative Code - residential care rules

September 5, 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 16, 2023Licensure survey1 deficiency▼

R-0614Notify director when normal business interruption due to emergency/disasterOhio citation · correction confirmed 10/26/2023▼

What the surveyor found

Based on staff interview and record review, the facility failed to evacuate residents capable of self-evacuation to safe areas or to the exterior of the residential care facility in at least two fire drills a year on each shift as required and failed to ensure fire drills conducted on the second and third shift were at various times as required. This had the potential to affect all residents. The facility census was 46.

Findings include:

1. Review of fire drill documentation from the July 2022 through July 2023 revealed no evidence residents capable of self-evacuation were evacuated.

Interview with Maintenance Director #950 on 08/15/23 at 2:10 P.M. verified no residents capable of self-evacuation were evacuated to safe areas or to the exterior of the residential care facility in at least two fire drills a year on each shift as required.

2. Review of Review of fire drill documentation from the July 2022 through July 2023 revealed drills on the second shift (3:00 P.M. to 11:00 P.M.) were conducted at 3:30 P.M., 4:14 P.M., 4:00 P.M. and 3:35 P.M. Further review of the documentation noted drills on the 3rd shift (11:00 P.M. to 7:00 A.M.) were conducted at 6:15 A.M., 6:30 A.M. and 6:50 A.M.

Interview with Maintenance Director #950 on 08/15/23 at 2:15 P.M. verified drills were not conducted at various times during the second and third shift as required.

Review of the fire drill instructions in the facilities electronic fire and disaster drill tracking system revealed 1. Drills are to be no closer than two hours apart from the last time recorded and not in the same hour during the year for any shift.

This deficiency is an example of continued non-compliance from the surveys completed on 07/19/18 and 11/05/19.

Rule

Ohio Administrative Code - residential care rules

June 15, 2023Complaint survey1 deficiency▼

R-0333Personal care services provided appropriatelyOhio citation · correction confirmed 08/16/2023▼

What the surveyor found

Based on record review and interview, the facility failed to ensure residents received bathing as planned. This affected five of five residents reviewed (#16, #19, #24, #26, and #37) and had the potential to affect the remaining seven residents (#6, #9, #18, #23, #28, #38, and #41) on the unit. Facility census was 50.

Findings include:

1. Review of the medical record for Resident #16 revealed an admission date of 01/12/22 with diagnosis including Alzheimer's disease. Review of the Mini-Mental State Examination (MMSE) dated 01/12/22 revealed the resident had impaired cognition.

Review of the Functional Evaluation dated 02/11/23 revealed Resident #16 required assistance of two staff during bathing twice a week.

Review of the service plan for bathing effective 12/29/2021 revealed two team members needed to physically assist Resident #16 with a bath or shower twice a week.

Review of the Service check off sheet for May 2023 indicated showers were completed on 05/04/23, 05/08/23, 05/12/23, and 05/18/23.

2. Review of the medical record for Resident #19 revealed an admission date of 06/25/21 with diagnosis including vascular dementia with behavioral disturbance. Review of the MMSE dated 06/05/21 revealed Resident #19 had severely impaired cognition.

Review of the Functional Evaluation dated 06/15/22 revealed Resident #19 required assistance of one staff twice a week for bathing.

Review of the service plan for bathing effective 10/27/2021 revealed Resident #19 required assistance of one staff twice a week with a bath or shower.

Review of the Service check off sheet for May 2023 revealed bathing or showers were completed on 05/06/23 and 05/12/23.

3. Review of the medical record for Resident #24 revealed an admission date of 12/08/22 with diagnoses including dementia, chronic obstructive pulmonary disease (COPD), and hypertension. Review of the MMSE dated 12/08/22 revealed the resident had impaired cognition.

Review of the Functional Evaluation dated 01/17/23 revealed Resident #24 required assistance on one staff every Tuesday and Friday with a bath or shower.

Review of the service plan for bathing dated 06/13/23 revealed Resident #24 required assistance of one staff twice a week with a bath or shower.

Review of the Service check off sheet for May 2023 revealed bathing or showers were completed on 05/05/23 and 05/09/23.

4. Review of the medical record for Resident #26 revealed an admission date of 04/15/22 with diagnoses including dementia, congestive heart failure, and chronic renal disease. Review of the MMSE dated 04/15/22 revealed the resident had impaired cognition.

Review of the Functional Evaluation dated 05/31/23 revealed Resident #26 received outside assistance with bathing.

Review of the service plan for bathing dated 04/14/23 revealed Resident #26 required assistance of one person twice a week with a bath or shower.

Review of the Service check off sheet for May 2023 revealed a bath or shower was completed on 05/04/23, 05/08/23, and 05/18/23.

5. Review of the medical record for Resident #37 revealed an admission date of 10/11/22 with diagnoses including cognitive Impairment, depression, and hypothyroidism. Review of the MMSE dated 10/11/21 revealed the resident had severely impaired cognition.

Review of the Functional Evaluation dated 11/16/22 revealed Resident #37 required assistance of one staff for bathing.

Review of the service plan for bathing effective 10/26/21 revealed Resident #37 required assistance of one staff twice a week with a bath or shower.

Review of the service check off sheet for May 2023 revealed bathing was completed on 05/04/23 and 05/18/23.

Review of June 2023 Resident Care Check off Sheets for the Garfield neighborhood revealed the service check off sheets had been completed on a limited number of days. Of the eight days completed, six of the days had no residents on the unit marked as having been bathed or showered.

Interview on 06/14/23 at 2:06 P.M. with Eastern National Clinical Specialist #303 verified bathing/showers for Residents #16, #19, #24, #26, and #37 were not consistently documented.

This violation represents non-compliance investigated under Complaint Number OH00143065.

Rule

Ohio Administrative Code - residential care rules

December 5, 2022Complaint survey1 deficiency▼

R-0711Free from abuseOhio citation · correction confirmed 08/16/2023▼

What the surveyor found

Based on record review, review of the facility self-reported incident (SRI), staff interview, and policy review the facility failed to ensure Resident #3 was free from physical abuse. This affected one (Resident #3) of three residents reviewed for abuse. The facility census was 57.

Findings include:

Review of Resident #3's medical record revealed the resident was admitted to the facility on 05/25/21 with diagnoses including hypertension, sciatica, and hypothyroid. Review of Resident #3's service plan dated 12/05/22 revealed the resident was alert and oriented and was independent to physical assist of one for activities of daily living (ADL).

Review of Resident #15's medical record revealed the resident was admitted to the facility on 01/12/22 with diagnoses including Alzheimer's disease and hyperlipidemia. Review of Resident #15's service plan dated 12/05/22 revealed the resident was alert and oriented and was independent for ADL.

Review of the Self-Reported Incident (SRI) tracking number 229578 revealed Resident #15 was physically aggressive when he entered the room of Resident #3 and threw her into the heater and/or air conditioning unit causing her to hit her head causing an abrasion to her right elbow. Review of the SRI revealed Resident #3 was sent to the local emergency room and did not return to the facility until 24 hours later after staying overnight with Family Member (FM) #900 due to feeling anxious and upset. Review of the SRI revealed Resident #3 was also sent to the emergency room and then to the geriatric psychiatric unit for further treatment.

Review of the incident investigation report revealed on 11/23/22 at approximately 4:45 P.M. Resident #15 walked into Resident #3 room and shoved and/or pushed her down into the heating unit causing a bump to the back of her head and a scrap to right elbow. Review of the incident report revealed Resident #15 reported Resident #3 came into the hallway and then went back into her room to get Kleenex. Resident #15 then entered Resident #3's room and told her she was going to pay for all the things she had done and pushed her down. Resident #15 reported he did it because Resident #3 started it and it was payback. Review of the investigation report revealed Resident #3 was found on the ground with her head on her heating unit. Both Resident #3 and #15 were separated and executive director, 911, families, and the physician were notified. Resident #15 was sent to the emergency room for a direct admit to geropsychiatry for an evaluation and workup.

Review of the progress note dated 11/23/22 at 6:36 P.M., located in Resident #3 electronic medical record, revealed she rang her call button for help at approximately 4:45 P.M. and was found on the floor sitting with her back against the heating, ventilation, and air conditioning (HVAC) unit. Resident #3 reported she was walking to the dining room when she returned to her room for tissue when Resident #15 followed her, yelled you're going to pay for everything you've done and threw her to the ground resulting in her hitting her head and right elbow. Review of the progress note revealed Resident #3 had a goose egg on the back right side of her head and abrasion to right elbow.

Review of the progress note dated 11/23/22 at 6:41 P.M., located in Resident #15 electronic medical record, revealed he followed Resident #3 into her room and yelled you're going to pay for everything you've done and threw her to the ground causing her to strike her head on the HVAC unit. Resident #15 was found on the couch in his room, agitated, and stated That [expletive] threw me down first.

Review of the facility document titled Elder Abuse/Neglect

Rule

Ohio Administrative Code - residential care rules