Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 London Health & Rehab Center during CMS and state inspections, most recent first.
Surveyors found that multiple resident rooms contained uncovered soffits above windows where pipes with gray to black speckled staining and white, flaking paint-like material were visible behind fabric valances. These conditions were observed in rooms occupied by residents with complex medical conditions such as COPD, CHF, CKD, DM2, dysphagia, dementia, seizures, and adult failure to thrive. The Maintenance Director confirmed the recurring discoloration and flaking on the pipes and acknowledged it did not align with a homelike environment. The facility had been aware of the issue for several months, despite a resident handbook statement that it promotes a homelike environment and accommodates reasonable requests to individualize living spaces.
The facility did not offer or provide the COVID-19 vaccine to staff members, even though the vaccine was available on site. Documentation and staff interviews confirmed that the updated vaccine was not administered to team members, potentially impacting all residents.
Staff did not ensure that medications were properly labeled and securely stored, as multiple medication carts contained loose, unidentified pills and opened inhalers without dates of opening. LPNs confirmed these findings, and the facility's policy and manufacturer instructions requiring dating and original container storage were not followed.
Multiple rooms were found with exposed drywall, black spots, and improperly stored televisions with exposed screws, as well as gouges in the wall near a resident's bed. These conditions were confirmed by the Maintenance Director and affected residents with significant medical needs.
Two residents with significant cognitive and physical impairments were subjected to disrespectful and belittling treatment by a CNA, including rude comments during personal care and dismissive responses to requests for assistance. Witnesses, including another CNA, a roommate, and a family member, confirmed the unprofessional conduct, which caused emotional distress and left residents in unpleasant conditions, in violation of facility policy requiring respect and dignity for all residents.
A resident with significant care needs was subjected to inappropriate and threatening behavior by a CNA, including delayed care, rough handling, and verbal threats. Another resident witnessed the incident and provided a statement. The facility failed to report this abuse allegation to the State Survey Agency as required by policy, and the Administrator confirmed the incident was not reported.
A resident with CVA and depression, dependent on staff for care, was subjected to unprofessional and threatening behavior by a CNA, including rough handling, exposure, and verbal threats. The facility did not conduct a thorough investigation, failing to interview potential witnesses or promptly inform the administrator, in violation of its abuse policy.
A resident with a physician-ordered fluid restriction due to CHF was served more fluids than allowed at breakfast, as staff were unaware of the restriction and did not follow the prescribed limits. Facility policy required licensed nurses to monitor and verify fluid intake, but this was not done, resulting in the resident receiving excess fluids.
A resident with severe cognitive impairment was allowed to sign a binding arbitration agreement without evidence that the agreement was explained in an understandable manner or that a legally authorized representative was involved. The admissions staff was aware of the resident's cognitive status but proceeded with obtaining the resident's signature after unsuccessful attempts to contact the family or POA.
Two CNAs provided catheter care to a resident with an indwelling catheter, who was on Enhanced Barrier Precautions, without wearing the required gloves and gown. Both staff acknowledged not using PPE despite signage and facility policy requiring it for high contact care activities, in line with CDC guidelines.
A resident with multiple chronic conditions and an indwelling urinary catheter was prescribed Bactrim DS for a UTI without follow-up urine culture or sensitivity testing, despite initial culture results indicating possible contamination and a facility policy requiring diagnostic confirmation before antibiotic use. An LPN confirmed that no further testing was performed, resulting in a failure to ensure appropriate antibiotic stewardship.
A resident with cognitive impairment and high fall risk did not consistently have required fall prevention interventions, such as a fall mat and Dycem on the wheelchair, in place as ordered and care planned. Staff confirmed these items were missing during observations, and the resident was not aware of education regarding their use, resulting in a failure to maintain adequate supervision and accident hazard prevention.
Failure to Maintain Homelike Room Environment Due to Stained and Deteriorating Pipes
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a homelike environment in multiple resident rooms after receiving vendor recommendations. Observations on 02/20/26 revealed that numerous rooms had uncovered soffits above the windows, concealed only by structured fabric window valances. When the valances were lifted, pipes of various shapes and sizes were visible, showing deep gray to black speckled staining and layers of white, flaking paint-like material. This condition was consistently observed in the rooms of Residents #24, #22, #23, #27, #28, #29, #30, #16, #71, #72, #14, #73, and #74. Resident #24, admitted on 01/23/26 with multiple sclerosis, depression, muscle weakness, fatigue, orthostatic hypotension, and transient ischemic attack, had such stained and flaking pipes above the window in their room. Similar conditions were documented for Resident #22, admitted with hemiplegia, pain, dysphasia, chronic kidney disease, and major depressive disorder, and Resident #23, admitted with syncope and collapse, muscle weakness, dysphagia, cognitive communication deficit, and seizures. In each of these rooms, surveyors observed the same pattern of uncovered soffits, visible piping, gray to black speckled staining, and white flaking paint-like material behind the valances. The same environmental condition was also present in the rooms of other residents with significant medical conditions. Resident #27, with COPD, vascular dementia, systolic heart failure, cognitive communication deficit, muscle weakness, emphysema, dysphagia, acute kidney failure, and altered mental status, and Resident #28, with cerebral infarction, encephalopathy, seizures, dysphagia, altered mental status, and cognitive communication deficit, had stained and flaking pipes above their windows. Residents #29, #30, #16, #71, #72, #14, #73, and #74, each with multiple serious diagnoses including adult failure to thrive, pulmonary hypertension, acute respiratory failure, Type 2 DM, glaucoma, heart failure, COPD, dementia, traumatic subdural hemorrhage, cerebral infarction, aphasia, and dysphagia, were also found to have the same visible staining and flaking material on pipes above their windows. During interviews and joint observations, the Maintenance Director confirmed the presence of the staining and flaking material on the pipes above resident windows and acknowledged that the discoloration did not align with a homelike environment. He stated he was unable to remedy the discoloration with paint due to its recurrence. The Administrator reported that the facility had been aware of the issue since late summer or early fall and that the facility had obtained vendor evaluation and recommendations for aesthetic resolution. The resident handbook dated 07/14/11 stated that the facility promotes a homelike environment and will make every attempt to accommodate reasonable requests to individualize residents’ living spaces, which contrasted with the observed stained and deteriorating pipe surfaces in the resident rooms.
Failure to Offer COVID-19 Vaccine to Facility Staff
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccine was offered or provided to staff members, despite the vaccine being available on site. Review of facility documentation showed that the updated COVID-19 vaccine would not be administered to team members at the facility. This was confirmed during an interview with a corporate registered nurse, who verified that the vaccine was not offered or provided to staff. This deficiency had the potential to affect all 70 residents in the facility, as staff vaccination is a key component in preventing the spread of COVID-19 within the facility. No information was provided regarding the vaccination status of individual residents or staff, nor were any specific medical histories or conditions mentioned in relation to the deficiency.
Failure to Properly Label and Store Medications
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were properly labeled and securely stored according to professional standards and facility policy. Observations of multiple medication carts revealed loose, unidentified pills of various shapes and colors, with no indication of which residents they belonged to. Additionally, several inhalers prescribed to specific residents were found opened without the required date of opening, contrary to manufacturer instructions and facility policy. These deficiencies were confirmed through staff interviews and review of the facility's medication storage policy, which mandates that medications with shortened expiration dates be dated upon opening and that all medications be stored in their original containers. The issues were identified across several medication carts, affecting medications for multiple residents. The lack of proper labeling and storage was verified by LPNs during the survey, and the facility's own census and policy reviews corroborated the findings. Manufacturer instructions for the inhalers in question specify that they should be discarded six weeks after opening, but the absence of opening dates made it impossible to determine compliance. The facility's policy also requires that medications be stored in their original containers, a standard not met in these instances.
Resident Rooms Not Maintained in Safe and Homelike Condition
Penalty
Summary
Surveyors observed that several resident rooms were not maintained in a safe, comfortable, and homelike manner. Specifically, rooms shared by three residents had exposed drywall with black spots near the window, and a television that had been removed from its wall mount was left sitting on a nightstand with exposed screws. The Maintenance Director confirmed these conditions and stated that the window leaks had caused the drywall issue. Additionally, gouges were observed in the drywall by another resident's bed, which was also verified by the Maintenance Director. The residents affected included individuals with complex medical histories, such as a resident with a left tibia fracture, anemia, intellectual disabilities, epilepsy, cerebral palsy, cognitive communication deficit, and depression. The observations and staff interviews confirmed that the facility failed to maintain the physical environment of resident rooms in a manner that supports safety, comfort, and a homelike atmosphere.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by multiple incidents involving two residents with significant cognitive and physical impairments. One resident, who was moderately cognitively impaired and dependent on staff for most activities of daily living, experienced repeated disrespectful and belittling comments from a CNA during personal care. The CNA expressed frustration about having to change the resident frequently due to incontinence, made derogatory remarks about the resident's condition, and spoke in a rude manner, which caused the resident emotional distress, including crying and withdrawal. These incidents were corroborated by witness statements from another CNA, the resident's roommate, and the resident's family, all of whom described the CNA's behavior as unprofessional and hurtful. Another resident, who was rarely or never understood and dependent on staff for toileting and mobility, was also subjected to disrespectful treatment. During a resident council meeting, it was reported that the same CNA responded to a request to empty a trash can containing vomit in a dismissive and unprofessional manner, stating she was too busy and questioning if she needed to "babysit" the residents. The CNA delayed emptying the trash for several hours, leaving the residents in an unpleasant environment. This incident was reported by a roommate who witnessed the CNA's conduct and the impact it had on the affected resident. The facility's policy requires that all residents be treated with respect and dignity, and that care be provided in a manner that maintains or enhances each resident's quality of life. However, the documented actions and statements of the CNA in these incidents demonstrate a failure to uphold these standards, resulting in a lack of respect and dignity for the residents involved.
Failure to Report Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Survey Agency, as required by policy. Medical record review showed that a resident with a history of cerebrovascular attack and depression, who was dependent on staff for mobility and communication, was involved in an incident where a CNA responded inappropriately to the resident's call light, delayed care, and made unprofessional and threatening remarks. The CNA also left the resident exposed and unattended, handled the resident roughly during a transfer, and placed the resident back into a dirty bed. Witness statements from another resident corroborated the events, including the CNA's use of her cell phone during care and her verbal threats toward the resident. Despite the seriousness of the allegations, the facility's Self-Reported Incidents (SRI) log did not include this incident, and the Administrator confirmed that the abuse allegation was not reported to the Ohio Department of Health. The Administrator stated he was unaware of the abuse aspect of the incident until several days later and acknowledged that the required report was not filed. Facility policy mandates immediate reporting of all abuse allegations to the Administrator, DON, and the State Agency, but this protocol was not followed in this case.
Failure to Investigate Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a resident with a history of cerebrovascular attack (CVA) and depression, who was dependent on staff for mobility and communication. According to medical records and witness statements, the resident activated the call light and waited 20 minutes before a CNA responded while on her cell phone, spoke unprofessionally, and delayed providing care. The CNA later transferred the resident roughly to a shower chair, left the resident exposed and unattended while continuing a personal phone call, and returned the resident to a dirty bed. The CNA also made inappropriate comments, including threatening language, towards the resident. The investigation into the incident was incomplete. The facility did not conduct interviews with other residents or staff who may have witnessed the alleged abuse, and the administrator was not fully informed of the abuse allegation until several days after the incident. The facility's policy required immediate investigation of all abuse allegations, but this was not followed, as confirmed by the administrator and human resources director. The lack of a thorough investigation and timely response constituted a failure to respond appropriately to the alleged violation.
Failure to Follow Physician-Ordered Fluid Restriction
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician-ordered fluid restriction for a resident diagnosed with COPD, vascular dementia, and congestive heart failure. The physician's order specified a 2,000 cc fluid restriction per 24 hours, with dietary and nursing staff assigned specific amounts to provide at each meal and shift. The care plan identified the resident as being at risk for nutrition and hydration issues related to CHF, with interventions to monitor for dehydration and fluid overload and to encourage adequate fluid intake. On observation, the resident was served a breakfast tray containing a total of 1,440 cc of fluids (480 cc each of pop, orange juice, and hot tea), which exceeded the amount allotted for that meal. A CNA who served the fluids stated she was unaware of the resident's fluid restriction. Review of facility policy indicated that licensed nurses are responsible for recording and verifying fluid intake for residents on fluid restrictions, but this process was not followed, resulting in the resident receiving more fluids than ordered.
Failure to Ensure Cognitively Impaired Resident Understood Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident was properly informed about a binding arbitration agreement in a manner the resident could understand prior to signing. Medical record review showed that the resident was admitted with multiple diagnoses, including severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 03. Despite this, the resident was allowed to sign the arbitration agreement without documented evidence that the agreement was explained in an understandable way or that a legally authorized representative was involved in the process. Further review revealed that the Admissions Coordinator attempted to contact the resident's family and Power of Attorney at the time of admission but was unable to reach them. Acknowledging the resident's cognitive impairment, the Admissions Coordinator still permitted the resident to sign the arbitration agreement. The agreement itself stated that the parties understood and voluntarily entered into arbitration, but there was no indication that the resident, given their cognitive status, could comprehend the agreement at the time of signing.
Failure to Use PPE During Enhanced Barrier Precautions for Catheter Care
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) protocols during the provision of catheter care for a resident with multiple medical conditions, including an indwelling catheter. Despite a sign on the resident's door indicating the need for gloves and a gown during high contact care activities, two Certified Nursing Assistants (CNAs) did not don the required personal protective equipment (PPE) while performing catheter care. Both CNAs confirmed in interviews that they were aware the resident was on EBP and acknowledged not wearing gloves or a gown during the procedure. The resident involved had a history of cerebrovascular disease, a right arm fracture, obstructive and reflux uropathy, dysphagia, cognitive communication deficit, difficulty walking, arteriosclerotic heart disease, age-related physical debility, and a lumbar vertebrae compression fracture. The resident was severely cognitively impaired, used a wheelchair, and had a physician's order for foley catheter care every shift, as well as an order for EBP due to the presence of the catheter. Facility policy and CDC guidelines require the use of gloves and gowns for high contact care activities for residents on EBP, particularly those with indwelling devices, but these protocols were not followed during the observed care.
Failure to Ensure Appropriate Antibiotic Use for UTI
Penalty
Summary
The facility failed to ensure appropriate antibiotic use for a resident with a urinary tract infection (UTI). Medical record review showed that the resident, who had multiple complex diagnoses including chronic obstructive pulmonary disease, respiratory failure, Parkinson's disease, and an indwelling urinary catheter, was prescribed Bactrim DS for a UTI. The resident's care plan included regular catheter care and interventions to prevent infection. However, the hospital record indicated that the initial urine culture showed mixed microbial growth with suspected contamination and recommended recollection and further work up. No sensitivity testing was performed, and no follow-up urine culture was completed to confirm the appropriateness of the prescribed antibiotic. Further review of the resident's medical record confirmed that no additional urine cultures or sensitivity testing were conducted to determine if Bactrim was an appropriate treatment. Staff interview with an LPN verified that no culture and sensitivity testing was performed. The facility's antimicrobial stewardship policy required the use of revised McGeer's Criteria and appropriate diagnostic testing to ensure antibiotics were prescribed only when necessary and appropriate, but these steps were not followed in this case.
Failure to Consistently Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented for a resident identified as high risk for falls. The resident, who had diagnoses including cognitive impairment, muscle weakness, unsteady gait, and was dependent on staff for mobility and toileting, had a care plan and physician orders specifying multiple fall prevention measures such as a fall mat, hipsters, Dycem on the wheelchair, perimeter mattress, and grippy socks. Despite these interventions being documented, observations revealed that the Dycem was not present on the resident's wheelchair and the fall mat was not in place while the resident was in bed during the day. Staff confirmed these interventions were missing at the time of observation. Additionally, the resident did not recall being educated on the use of the Dycem, and staff interviews indicated that the fall mat was only placed at night. The facility's policy required individualized fall prevention interventions to be implemented and maintained based on assessment and care planning. However, the lack of consistent implementation of these interventions, as observed and confirmed by staff, constituted a failure to provide adequate supervision and maintain an environment free from accident hazards for a resident at high risk for falls.
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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 London
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbors West | 9.5 mi | ★★★★★ | 4 | 0 |
| Laurels Of West Columbus, The | 16.3 mi | ★★★★★ | 11 | 1 |
| Good Shepherd Village | 17.2 mi | ★★★★★ | 0 | 0 |
| Northwood Skilled Nursing And Rehabilitation | 17.6 mi | ★★★★★ | 4 | 0 |
| Forest Glen Rehabilitation And Healthcare Center | 17.7 mi | ★★★★★ | 12 | 0 |
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