Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chardon Woods during CMS and state inspections, most recent first.
A resident with a history of behavioral issues inappropriately kissed another resident, who was rarely understood and had significant cognitive and psychiatric diagnoses. The incident was witnessed by a CNA and reported to an LPN, but the affected resident later expressed feeling abused and not wanting to remain on the same unit as the other resident. The facility failed to prevent the abuse despite the known behavioral history of the perpetrator.
The facility did not provide structured activities for residents in the memory care unit, affecting all 27 residents. Activity calendars lacked specific activities for the unit, and scheduled activities were often not conducted. Observations and interviews confirmed the absence of activities, with only the Activity Director and an assistant responsible for conducting them. The facility's policy to meet residents' interests and well-being was not fulfilled.
The facility failed to include two residents and/or their representatives in quarterly care plan meetings. One resident, severely cognitively impaired, missed a meeting between May and November, while another, with impaired thought processes, had a meeting attended only by the Social Service Designee. The facility's policy required resident involvement in care plan discussions.
A facility failed to ensure a resident was offered a mouth rinse after using a steroidal inhaler, as observed during medication administration by an RN. The resident's care plan and physician's orders lacked instructions for mouth rinsing, despite the risk of fungal infections. Interviews with the facility's Regional RN and contracted Pharmacist confirmed the necessity of this practice, which was also supported by the inhaler's package insert and facility policy.
A resident with multiple health conditions was found to be using oxygen without a physician's order or an updated care plan. The oxygen tubing was not labeled or dated, and the resident reported removing the nasal cannula due to irritation. Facility policy requires physician orders and proper documentation for oxygen therapy, which were not followed.
A facility failed to maintain infection control standards during medication administration, affecting two residents. An RN was observed handling medications with ungloved hands and not performing hand hygiene between residents. The facility's policy required handwashing but did not explicitly prohibit touching medications with bare hands.
Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when another resident approached and kissed him on the lips without consent in a common area. The incident was witnessed by a CNA, who reported it to an LPN. The resident who was kissed had a history of being rarely or never understood, with diagnoses including unspecified intracranial injury, bipolar disorder, and anxiety disorder. The resident who initiated the contact had a documented history of behavioral issues, including sexual inappropriateness, psychosis, and other disruptive behaviors. Documentation revealed that the resident who was kissed did not initially respond to questions about the incident, but later interviews indicated he felt abused by the event and expressed a desire not to reside on the same unit as the other resident. The resident who initiated the contact was sent to the hospital following the incident. Staff interviews and progress notes confirmed that the incident was categorized as alleged physical abuse, but the facility concluded that abuse did not occur. However, the surveyor's interview with the affected resident revealed he felt abused and did not want to remain on the same unit as the other resident. The facility's records showed that the resident who initiated the inappropriate contact had a known history of sexually inappropriate behaviors and other disruptive actions, yet remained on the same unit as vulnerable residents. The incident was not documented in the initial physician assessment for the affected resident, and there was no evidence that the resident's expressed wishes to be moved were known to staff prior to the surveyor's interview.
Lack of Structured Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide structured and routine activities for residents in the memory care unit, affecting all 27 residents in that unit. The activity calendars from January 2024 through January 2025 did not include specific activities for the memory care unit, and there were significant gaps in scheduled activities, particularly on Tuesdays, Wednesdays, and after 3:00 PM on Saturdays. Observations on multiple dates revealed that scheduled activities were not conducted, and interviews with residents and staff confirmed the lack of activities. A resident expressed that activities were rarely held, and a CNA reported that activities were not prioritized in the memory care unit. The Activity Director and an activity assistant were the only staff responsible for activities, with the director covering weekdays and the assistant on weekends. The Activity Director admitted to conducting only two activities in the memory care unit and two upstairs, with room visits in between when possible. Most residents in the memory care unit required one-on-one activities, which were not consistently provided. The facility's policy stated that activities should meet the interests of each resident and support their well-being, but this was not being fulfilled in the memory care unit.
Failure to Include Residents in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were able to participate in quarterly care plan conferences, affecting two residents. Resident #62, who was severely cognitively impaired with a BIMS score of 00, did not have a quarterly care plan meeting between May and November 2024. The resident's medical record indicated a need for assistance with daily activities and a care plan addressing behavior problems. The Social Service Designee confirmed the absence of a quarterly care plan meeting during this period. Resident #10, who was cognitively intact with a BIMS score of 15 but had impaired thought processes due to paranoid schizophrenia, also did not have a proper care plan meeting. The annual care plan meeting scheduled for November 2024 was attended only by the Social Service Designee, without the resident or other members of the Interdisciplinary Team. The facility's policy required the involvement of residents and/or their representatives in care plan discussions, which was not adhered to in these cases.
Failure to Offer Mouth Rinse After Steroidal Inhaler Use
Penalty
Summary
The facility failed to ensure that Resident #102 was offered to rinse his mouth after the administration of a steroidal respiratory inhaler, specifically Pulmicort Flexhaler. This oversight was observed during a medication administration by RN #553, who admitted to not offering the resident a mouth rinse post-inhalation, as she was unaware of its importance in preventing fungal infections. The resident's care plan and physician's orders did not include instructions for mouth rinsing after inhaler use, despite the known risk of fungal infections associated with steroidal inhalers. The deficiency was confirmed through interviews with the facility's Regional RN and contracted Pharmacist, both of whom acknowledged the necessity of mouth rinsing after steroidal inhaler use to prevent fungal infections. Additionally, the package insert for Pulmicort Flexhaler and the facility's own policy on the administration of metered-dose inhalers both recommended rinsing the mouth post-inhalation. This failure to adhere to professional standards and guidelines had the potential to affect eight residents in the facility who were prescribed respiratory inhalers.
Deficiency in Oxygen Therapy Management
Penalty
Summary
The facility failed to ensure that a physician's order and care plan for the use of oxygen were in place for a resident, identified as Resident #94. This resident had multiple diagnoses, including chronic kidney disease, vascular dementia, heart failure, fluid overload, primary hypertension, and atrial fibrillation. Despite these conditions, the resident's medical record and care plan did not reflect the use of oxygen therapy, and there was no physician's order for oxygen. An observation revealed that the resident had an oxygen concentrator running at 2.5 liters, but the nasal cannula was on the floor and not attached to the resident. The resident mentioned removing the nasal cannula due to irritation. Further investigation showed that the oxygen tubing was not labeled or dated, contrary to the facility's policy, which requires labeling and changing the tubing every 72 hours. Interviews with the nursing staff and administration confirmed the absence of a physician's order for oxygen and the lack of an updated care plan addressing oxygen therapy. The facility's policy mandates that oxygen be administered under a physician's order, with documentation of the resident's condition and response to therapy, which was not adhered to in this case.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control standards during medication administration, affecting two residents out of five reviewed. Resident #69, with chronic kidney failure, pulmonary embolism, and protein-calorie malnutrition, and Resident #102, with hypertension, allergic rhinitis, and congestive heart failure, were involved. On the morning of January 14, 2025, RN #533 was observed preparing and administering medications without using gloves and without performing hand hygiene between residents. Specifically, RN #533 used ungloved hands to handle medications directly from bottles, break tablets, and pick up medications from the medication cart, which were then administered to the residents. During an interview, RN #533 confirmed the actions and expressed a lack of awareness regarding the facility's infection control standards, citing previous practices from a hospital setting. The facility's policy on medication administration, dated February 10, 2024, required adherence to professional standards to prevent contamination or infection, including handwashing after medication administration. However, the policy did not explicitly prohibit touching medications with bare hands. Regional RN #630 verified that hand hygiene should be performed between each resident and that medications should not be handled with ungloved hands.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chardon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mapleview Country Villa | 2 mi | ★★★★★ | 4 | 0 |
| Chardon Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Ohman Family Living At Holly | 4.3 mi | ★★★★★ | 7 | 0 |
| Burton Health Care Center | 6.1 mi | ★★★★★ | 0 | 0 |
| Autumn Hills Healthcare Community | 6.6 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.