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 Mentor Hills Post Acute during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including cancer and undergoing chemotherapy, missed a scheduled Hematology and Oncology infusion appointment because transportation was not arranged during the responsible Unit Manager's vacation. Facility staff confirmed the oversight, and documentation showed the appointment was not entered into the transportation calendar or medical record, despite facility policy requiring assistance with transportation.
The facility failed to implement proper infection control measures, including transmission-based and enhanced barrier precautions, for several residents. A resident with C-Diff did not have appropriate contact precaution signage, leading to inadequate protective measures by staff. Additionally, wound care for multiple residents was conducted without proper hand hygiene and PPE, risking cross-contamination. These deficiencies were confirmed by the RN/WN/IP and the DON, indicating systemic issues in infection prevention protocols.
A facility failed to hold quarterly care conferences for a resident with multiple diagnoses, including heart failure and paraplegia. The resident, who was alert and cooperative, had only three documented care conferences over an extended period. Interviews revealed the resident understood care conferences but had not attended one recently, and the social worker confirmed the lack of quarterly meetings. There was no documentation of efforts to schedule these meetings as per facility policy.
The facility failed to designate a Grievance Officer, potentially affecting all 96 residents. A review of the Grievance Committee list showed no staff member was assigned this role. The Administrator confirmed the absence of a designated Grievance Officer, despite the facility's policy requiring the Administrator to delegate this responsibility.
The facility failed to provide the correct portion size of an alternate entree during lunch, affecting two residents. The menu specified a one-cup portion of cheese ravioli, but only a half-cup was served. Interviews confirmed the error, which was investigated under a complaint.
The facility failed to implement a comprehensive pressure ulcer prevention program, resulting in new Stage III pressure ulcers for two residents. One resident developed ulcers on the scrotal and coccyx areas, while another had an ulcer on the right buttock. Observations showed missed wound care treatments, and interviews revealed documentation inconsistencies and staff unawareness of wound conditions. Multiple changes in wound care personnel contributed to the oversight.
The facility failed to complete and document treatments as ordered for two residents. One resident with an arterial ulcer did not have their dressing changed daily as required, and another resident with a fungal rash lacked documentation of treatment completion. Facility policies did not ensure proper documentation and completion of treatments.
The facility failed to maintain accurate medical records and ensure treatments were completed as ordered for two residents. One resident with an arterial ulcer did not receive daily dressing changes as ordered, and another with a pressure ulcer had missed dressing changes despite being documented as completed. The facility's policies did not ensure treatments were completed before documentation.
Failure to Arrange Transportation for Oncology Appointment
Penalty
Summary
The facility failed to ensure transportation was arranged for a resident to attend a scheduled Hematology and Oncology appointment for infusion therapy. The resident, who had diagnoses including malignant neoplasm of the right lung, cerebrovascular disease, and was receiving chemotherapy, was scheduled for an infusion appointment. Documentation showed that the appointment was missed due to a transportation error, specifically because the responsible Unit Manager was on vacation and the appointment was not scheduled on the transportation calendar. The resident's medical record did not contain a physician order for the missed appointment, and the facility's appointment calendar did not reflect the scheduled visit. Interviews with facility staff, including the Administrator, Unit Managers, Social Worker, and DON, confirmed that the missed appointment was due to a lack of transportation arrangements during the Unit Manager's absence. The facility's policy stated that assistance with arranging transportation would be provided as needed, but this was not followed in this instance. The deficiency was identified through review of records, interviews, and facility policy, and was substantiated by a resident grievance regarding the missed appointment.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions (TBP) and enhanced barrier precautions (EBP) for several residents, leading to potential infection control issues. Resident #84, diagnosed with Clostridium difficile (C-Diff), did not have the required contact precaution signage outside her room, leading staff to only follow EBP, which was insufficient for C-Diff. Housekeeping staff were not informed of the need for contact precautions, resulting in inadequate protective measures during cleaning. The Director of Nursing (DON) confirmed that contact isolation signage should have been posted, and housekeeping should have been instructed to wear gowns when cleaning the environment. In addition, the facility failed to adhere to proper wound care protocols for multiple residents. For Resident #1, the RN/Wound Nurse/Infection Preventionist (IP) did not perform hand hygiene after removing the old dressing before cleansing the wound. Similarly, for Resident #41, the RN/WN/IP did not wash hands between treating multiple wounds, risking cross-contamination. The DON confirmed that hand hygiene should have been performed after removing old dressings and that each wound should be treated separately. The facility's policy did not address the care of multiple wounds, contributing to the oversight. Furthermore, the facility did not consistently apply EBP as required. For Resident #58, the LPN administered intravenous antibiotics without wearing a gown, despite EBP requirements. Resident #57's wound care was conducted without proper EBP signage or PPE, and the RN/WN/IP failed to maintain a clean field and change gloves appropriately. Resident #12's wound care was also conducted without a gown, and gloves were not changed between cleansing and dressing application. These lapses in infection control practices were verified by the RN/WN/IP and the DON, highlighting a systemic issue in adhering to infection prevention protocols.
Failure to Hold Quarterly Care Conferences for a Resident
Penalty
Summary
The facility failed to hold quarterly care conference meetings for Resident #21, as required by their policy. Resident #21, who was admitted with diagnoses including chronic diastolic heart failure, paraplegia, morbid obesity, fibromyalgia, and colostomy, had only documented care conferences on three occasions over a period that should have included more frequent meetings. The resident was alert, cooperative, and had no memory impairment, indicating she was capable of participating in her care planning. However, there was no documented evidence that the resident or her daughter were offered the opportunity to attend quarterly care conferences. Interviews with Resident #21 revealed that she understood the purpose of care conferences but had not attended one for a long time. She mentioned having informal discussions with staff, such as the person in charge of the kitchen, but declined a group meeting due to concerns about illness exposure. The social worker confirmed that care conferences had not occurred quarterly and that the resident had requested her daughter be contacted instead. Despite this, there was no documentation to show that the facility made efforts to schedule these meetings at convenient times for the resident and her family, as per their policy.
Failure to Designate Grievance Officer
Penalty
Summary
The facility failed to ensure a designated Grievance Officer was identified, which had the potential to affect all 96 residents residing in the facility. A review of the Grievance Committee list revealed that no staff member had been designated as the Grievance Officer. During an interview with the Administrator, it was confirmed that there was no designated Grievance Officer. The facility's policy titled Grievances/Complaints, Filing, updated in April 2017, indicated that the Administrator is responsible for delegating a Grievance Officer, which was not done.
Inadequate Portion Size of Alternate Entree
Penalty
Summary
The facility failed to provide the alternate entree at the appropriate portion size during a lunch meal service, affecting two residents. The menu for Week Two indicated that the lunch meal on Wednesday should include cheese ravioli with marinara sauce, with a portion size of one cup for those on a regular diet. However, during the observation of the trayline setup, it was noted that a four-ounce spoodle was used to serve the ravioli, resulting in only a half-cup portion being provided instead of the required one cup. Interviews with the Certified Dietary Manager and the District Manager confirmed that the correct portion size should have been eight ounces, and if a four-ounce scoop was used, two scoops should have been provided. Two residents were identified as having received the insufficient portion size of ravioli. Interviews with these residents confirmed that they received the ravioli at lunch. This deficiency was investigated under Complaint Number OH00160242.
Inadequate Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program, resulting in the development of new pressure ulcers and inadequate wound care for two residents. Resident #51, who had a history of pressure ulcers and was dependent on staff for most activities of daily living, developed a Stage III pressure ulcer on his scrotal area and another on his coccyx. These ulcers required mechanical debridement, and there was no documented evidence of effective interventions to prevent their development or timely identification before reaching Stage III. Resident #79, also dependent on staff for most ADL care, developed a Stage III pressure ulcer on her right buttock, which required mechanical debridement. Observations revealed that her wound care dressing was not completed as ordered on two consecutive days, indicating a failure to follow physician orders and provide adequate wound care. The facility lacked documented evidence of effective interventions to prevent the development of this pressure ulcer and ensure timely identification. Interviews with facility staff, including the Regional RN, DON, and Wound NP, revealed inconsistencies in wound care documentation and a lack of awareness of residents' wound conditions. The facility experienced multiple changes in wound care personnel, contributing to the oversight and inadequate care. The facility's policies on dressing changes and skin care management did not ensure treatments were completed as ordered, leading to non-compliance with pressure ulcer prevention and care standards.
Failure to Document and Complete Resident Treatments as Ordered
Penalty
Summary
The facility failed to ensure that resident treatments were completed and documented as ordered, affecting two residents. Resident #58, who had an arterial ulcer on the left ankle, was supposed to have the dressing changed daily according to the Wound Nurse Practitioner's orders. However, the treatment administration record (TAR) indicated conflicting instructions, leading to the dressing being changed every other day instead of daily. Observations and interviews revealed that the dressing was not changed for a week, despite documentation indicating otherwise. Resident #93, diagnosed with Alzheimer's disease and other conditions, had a physician's order to cleanse her bilateral buttocks with soap and water, pat dry, and apply antifungal cream and powder every shift. However, there was no documentation in the TAR that this treatment was completed from the beginning of July until the 22nd. An observation of incontinence care showed skin changes, and interviews confirmed the lack of documentation for the required treatment. The facility's policies on medication administration and dressing changes were reviewed, revealing that they did not ensure treatments were completed as ordered or documented correctly. The deficiency was investigated under a specific complaint number, indicating non-compliance with the required standards of care.
Inaccurate Medical Records and Treatment Non-Compliance
Penalty
Summary
The facility failed to maintain accurate medical records and ensure treatments were completed as ordered for two residents. Resident #58, who had an arterial ulcer on the left ankle, was supposed to have daily dressing changes as per the Wound Nurse Practitioner's orders. However, the treatment administration record (TAR) indicated the dressing was changed every other day, and interviews revealed that the dressing was not changed for a week, despite being signed off as completed. This discrepancy was confirmed by the Wound Nurse Practitioner and the Registered Nurse/Wound Nurse, who found the dressing unchanged for a week. Similarly, Resident #79, who had a stage three pressure ulcer on the right buttock, was ordered to have daily dressing changes. The TAR showed the dressing was signed off as completed daily, but observations and interviews revealed the dressing was not changed on two consecutive days. The Wound Nurse Practitioner and the Registered Nurse/Wound Nurse confirmed the dressing was not changed as ordered, despite being documented as completed. The facility's policies on medication administration and dressing changes did not ensure treatments were completed as ordered or documented accurately. The policies required documentation of medication administration but did not address the need to verify completion of treatments before documentation. This deficiency was investigated under Complaint Number OH00155127.
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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 Mentor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mentor Ridge Health And Rehabilitation | 0.4 mi | ★★★★★ | 6 | 0 |
| Kirtland Woods Of Journey | 2.5 mi | ★★★★★ | 16 | 0 |
| Willoughby Post Acute | 3.7 mi | ★★★★★ | 2 | 0 |
| Concord Ridge Health And Rehabilitation | 4 mi | ★★★★★ | 0 | 0 |
| Ohio Living Breckenridge Village | 4.4 mi | ★★★★★ | 1 | 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.