Below 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 Mt Alverna Home Inc during CMS and state inspections, most recent first.
Repeated Meal Choices Limited Variety: A resident reported that meal choices were always the same, with a lot of pasta and potatoes and little variation in alternatives, and also stated food quality had declined over the last few months. Menu review showed multiple potato-based items served across breakfast, lunch, and dinner throughout the week, and a DT confirmed residents often complained about eating the same food items and verified the repeated menu pattern.
Meals were not served promptly enough to keep hot foods at proper temperatures, and food service staff did not consistently use hair restraints in food areas. Residents and a CNA reported that meals were often cold and late, and surveyors observed hot items sitting uncovered on the steam table while tray assembly and delivery were delayed, with some foods dropping below acceptable hot-holding temperatures. Surveyors also observed an RCA enter a kitchen area without a hairnet, contrary to facility policy.
Failure to Maintain Resident Dignity During Dining: Two residents with cognitive and physical impairments were observed in the dining room, where one resident received her lunch tray and began eating while the other sat without a tray. Other residents were served before the second resident, who received her tray last after the first resident had already finished and left. A CNA confirmed the observations.
Unidentified and Untreated Leg Wound: A resident with DM, venous insufficiency, and functional dependence developed a new leg wound that was not identified or treated until it was already large, infected, and partially healing. Family noticed leg swelling and a healing wound, and later documentation described a 5 cm by 7 cm wound with scabbing, drainage, redness, warmth, edema, and cellulitis; the Wound Nurse said the wound was hidden by ace wraps and should have been monitored daily.
Restorative nursing services were not consistently provided as ordered for three residents with significant care needs, including MS, dementia, contractures, and impaired mobility. One resident had orders for PROM, AAROM, and splint use; another had orders for restorative ambulation and AROM; and a third had orders for restorative ambulation and toileting. Care plans called for restorative sessions 3-6 times per week, but logs showed each resident received fewer sessions than ordered. Staff said restorative aides were repeatedly pulled to work as CNAs because of staffing shortages, and the DOT confirmed residents and families complained that restorative services were not being completed.
Mechanical Lift Transfer Fall: A resident with MS, contractures, scoliosis, and dependence for ADLs fell during a mechanical lift transfer when a strap became unhooked and she slid from the sling onto the floor, striking her head and left shoulder. The resident reported the CNAs were chatting and not paying attention, and interviews with the CNAs, an LPN, and the DON confirmed the transfer failure. Hospital records identified an accidental fall, acute head injury, cervical strain, and a left shoulder contusion, and the facility’s lift-transfer policy was not followed.
A resident with cerebral infarction, hemiplegia/hemiparesis, and HTN was ordered double portions for all meals with extra gravy and had a care plan intervention to honor food preferences. During lunch tray line observation, a DA acknowledged the resident was supposed to receive two potatoes but initially plated only one because he was unsure there would be enough, and the second potato was provided only after surveyor intervention.
A resident with diabetes and severe cognitive impairment did not have blood glucose testing performed before meals as ordered by the physician. Instead, BGT was completed after the resident had already eaten breakfast on two occasions, as confirmed by MAR review and staff interviews. The issue arose due to changes in the resident's care routine requested by the power-of-attorney and staff not realizing the resident had started eating.
The facility failed to maintain clean and sanitary conditions for food storage and preparation, affecting all residents consuming food from the kitchen. Observations revealed open and undated food items in both dry storage and the walk-in refrigerator, as well as a dirty fryer with unsuitable oil. The Assistant Dietary Manager acknowledged these issues, which were contrary to the facility's procedures for labeling and dating food items.
A facility failed to maintain an accurate medical record for a resident with severe cognitive impairment and multiple diagnoses. The resident's dietary notes showed discrepancies due to a mix-up by a Dietary Technician, who documented another resident's nutritional information into the wrong record, leading to inaccuracies.
The facility's kitchen was found unsanitary with food debris on the floor, dirty equipment, and undated food items in the refrigerator. Despite staff training on sanitation and food storage, these deficiencies were observed, affecting all residents receiving food from the kitchen.
The facility failed to follow the prescribed menu and portion sizes, affecting 29 residents. Staff served country fried steak without gravy due to confusion over meal tickets, and used an ineffective scoop for the watery gravy. Chicken dumpling soup was served in smaller portions than required, with mostly broth and little solid content. The brown gravy was improperly prepared with corn starch instead of flour. Despite training, staff did not adhere to menu and recipe guidelines, leading to non-compliance investigated under specific complaint numbers.
The facility failed to maintain appropriate food temperatures, affecting 29 residents. Observations and interviews revealed that meals intended to be hot were served lukewarm or cool. A test tray showed the food was below the required temperature, and the Dietary Director confirmed ineffective temperature maintenance due to recent procedural changes.
A facility failed to follow physician's orders for a resident's suprapubic catheter change, leading to a deficiency. The resident, with multiple sclerosis and bladder dysfunction, had orders for catheter changes every 30 days on the evening shift. However, records showed inconsistencies, with a Licensed Practical Nurse claiming a shift change request by the resident, which the resident denied. The lack of documentation and adherence to orders resulted in non-compliance.
Repeated Meal Choices Limited Variety
Penalty
Summary
The facility failed to ensure residents were served a variety of meal choices and instead provided menus with repeated potato-based items throughout the week. Review of the weekly menu dated 05/03/26 through 05/09/26 showed 5 of 7 breakfast meals, 5 of 7 lunch meals, and 4 of 7 dinner meals included some variation of potatoes, including breakfast potatoes, potato soup, hashbrown patties, mashed potatoes and gravy, herbed red potatoes, rosemary scalloped potatoes, baked potatoes, dill potatoes, and sweet potato fries. The facility census was 136, and the deficiency was identified as affecting all residents except three residents who were identified by the facility as not receiving food by mouth or from the kitchen. During interview, Resident #24 stated the food choices were always the same and rotated throughout each week, with a lot of pasta and potatoes and little variation in alternatives. The resident also stated the food quality had gone downhill over the last few months. During interview, Dietary Technician #829 stated residents often complained about eating the same food items, kitchen staff followed the menus provided, and the dietary director was responsible for switching things around. The DT reviewed the menus and confirmed the repeated potato variations noted in the findings.
Delayed Meal Service and Missing Hair Restraints in Food Areas
Penalty
Summary
Meals were not served in a timely manner to maintain proper temperature, and food service staff did not consistently follow sanitation practices related to hair restraints. Residents reported that meals were often cold and arrived late. A CNA stated that residents complained about cold and "nasty" food and that staff frequently had to call the kitchen because of resident complaints. One resident said the food was never hot and always arrived late, and another resident said the food was always cold and requested that trays be warmed or served first so meals could be eaten in the dining room. During observation of lunch service, dietary staff served dining rooms first and room trays last. Hot food items were observed on the steam table while tray assembly and delivery were delayed, and temperatures dropped between the steam table and the test tray at delivery, including soup and carrots falling below 135 degrees F and chicken measuring below acceptable hot holding temperature before tray pass. In a separate observation, a resident care assistant entered the third-floor kitchen without a hairnet or hair covering and went into the refrigerator. The facility policy required hair to be appropriately restrained with a hair net in any food production area.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to ensure residents were treated with dignity during dining. Resident #30 was admitted with diagnoses including hemiplegia and hemiparesis, hypertension, and hyperlipemia. Her assessments showed a memory problem, modified independence with tasks of daily life, impairment on one side of the upper and lower extremities, and dependence on staff for ADLs. Her care plan identified a self-care performance deficit related to hemiplegia, aphasia, and muscle weakness and directed staff to provide set-up and clean-up assistance with eating and dining assistance. Resident #103 was admitted with diagnoses including diverticulosis of the intestine, dementia, and impulse disorder. Her MDS assessment showed a BIMS score of 4 indicating cognitive impairment, and she required some assistance from staff for ADLs. During observation in the third floor dining room, Resident #103 received her lunch tray and began eating while Resident #30 sat at the table without her lunch tray. Resident #30 continued to sit without a tray while other residents in the dining room were served their lunch trays. Resident #103 finished her meal and left the dining room before Resident #30 received her tray last. A CNA confirmed and verified the observations.
Unidentified and Untreated Leg Wound
Penalty
Summary
The facility failed to ensure Resident #139’s new wound was identified and treated before it became larger, infected, and began healing without facility action. The resident was admitted with diagnoses including diabetes, venous insufficiency, and symbolic dysfunctions, and the admission assessment documented no edema along with wounds on the right and left toes and the top of the right foot. Records through 04/16/26 showed no assessment, treatment, or acknowledgement of a wound on the right lateral leg. A progress note dated 04/16/25 documented that family asked why the resident’s legs were swollen and identified a healing wound on the right lateral leg. A skin/wound note the same day measured the wound at 5 cm by 7 cm by 0.1 cm, with most areas scabbed over and a few areas with scant drainage. The next day, progress notes documented orange discoloration to the skin and antibiotics were ordered for infection of the wound. The treatment record showed dressings were ordered on 04/17/26 and continued until discharge. A later wound assessment identified the wound as an abrasion to the left lateral leg measuring 5 cm by 7 cm by 0.1 cm, with granulation tissue, warmth, redness, light serosanguinous drainage, and pitting edema; a freehand note linked the wound to edema and cellulitis. The Wound Nurse stated the wound developed in an area hidden by ace wraps and that the wraps should have been removed daily and skin changes reported to her office.
Restorative nursing services not provided as ordered
Penalty
Summary
The facility failed to ensure restorative nursing programs were implemented for three residents who had physician orders and care plans for restorative services. Resident #24 had diagnoses including multiple sclerosis, contractures of multiple sites, and scoliosis, and had orders for PROM to both upper extremities, AAROM to both lower extremities, and bilateral dynamic AFO splints for contracture management. Her care plan included restorative ADL training 3-6 times per week, and the restorative logs showed she received services only 8 times during the 30-day review period rather than the ordered frequency. Resident #31 had diagnoses including dementia, mild protein-calorie malnutrition, and dysphagia, with orders for restorative ambulation using a wheeled walker and AROM to both upper and lower extremities 3-6 times per week. Her care plan included restorative ambulation and AROM BUE sessions, but the participation log showed she received restorative services only 11 times during the 30-day review period. Resident #130 had diagnoses including dementia, solitary pulmonary nodule, and hypertension, with orders for restorative ambulation and toileting 3-6 times per week. Her care plan included restorative nursing for ambulation and ADL training for toileting, but her log also showed only 11 restorative sessions during the 30-day review period. Staff interviews confirmed that restorative aides were frequently pulled from restorative assignments to work as CNAs because of staffing shortages. A restorative aide stated she was scheduled to do restorative services every day but was pulled to the floor often, and another staff member confirmed restorative staff sometimes had to be reassigned to ADL care, causing restorative programs to be delayed or not completed. Additional interviews with CNA, RN, DOT, and staffing staff confirmed that restorative staff were used to cover floor staffing needs, and that residents on restorative programs, including the three identified residents, did not consistently receive services as ordered and care planned. The facility policy required restorative services to maintain or improve resident abilities, but the record review and interviews showed the policy was not implemented for these residents.
Mechanical Lift Transfer Fall
Penalty
Summary
The facility failed to provide care and services to prevent a fall during a mechanical lift transfer for Resident #24, who had diagnoses including multiple sclerosis, contractures of multiple sites, and scoliosis. The resident’s physician orders included two-person care for ADLs, and the care plan identified her as at risk for falls with interventions including use of a mechanical lift for transfers and two-person care. The MDS showed she was alert and oriented, impaired on both sides, and dependent on staff for ADLs. On 03/18/26, two CNAs were transferring the resident from bed to wheelchair using a mechanical lift when she slid out of the sling and fell to the floor with her head resting on the base of the lift. One strap became unhooked during the transfer, and staff lowered her to the ground. The resident stated that the CNAs were chatting and not paying attention, and that the strap was not in place before she fell backward and struck her head and left shoulder on the lift leg. The incident note documented that she landed on the floor, was assessed by nursing, and was sent to the hospital for evaluation. Hospital discharge paperwork identified an accidental fall, acute head injury, cervical strain, and contusion of the left shoulder, with imaging negative for fracture, hemorrhage, or other traumatic abnormality. Interviews with the CNAs, the LPN, and the DON confirmed that the resident slipped from the mechanical lift during the transfer and that the event was related to the strap becoming undone. Facility policy required two employees, use of the manufacturer’s instructions, and proper assembly and positioning of the equipment for a safe transfer, but the report states the facility did not implement the policy.
Meal Preferences Not Honored
Penalty
Summary
The facility failed to ensure resident meal preferences were honored for Resident #109, who was admitted with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting the right dominant side, and hypertension. Physician orders dated 03/05/25 directed that he receive double portions for all meals with extra gravy, and a later order dated 04/03/25 specified a general diet with regular texture and thin liquids. The care plan dated 04/29/25 noted variable food intakes and included honoring food preferences as an intervention. The MDS assessment showed a BIMS score of 12, indicating he was alert and oriented to person, place, and time, and that he was impaired on one side and required some assistance with ADLs.
Failure to Complete Blood Glucose Testing per Physician Orders
Penalty
Summary
The facility failed to ensure that blood glucose testing (BGT) was completed according to physician orders for a resident with diagnoses including encephalopathy, type 2 diabetes, and dementia. The resident had physician orders for sliding scale insulin coverage, which required BGT to be performed before meals and at bedtime. However, documentation revealed that on two occasions, BGT was performed after the resident had already consumed breakfast, rather than prior to the meal as ordered. This was confirmed by both the Medication Administration Record and staff interviews. The resident's power-of-attorney had requested that the resident not be woken up during the night or for breakfast, and that medication administration times be adjusted to when the resident was awake. Staff reported that on the days in question, the resident either woke up on their own or was awakened by family and began eating before staff realized, resulting in BGT being performed after meal consumption. The Director of Nursing confirmed that BGT was completed after breakfast on these dates, contrary to the physician's orders.
Deficiencies in Food Storage and Sanitation
Penalty
Summary
The facility failed to ensure that food was served and stored in a clean and sanitary manner, potentially affecting all 142 residents who consumed food from the kitchen. During an observation of the kitchen area with the Assistant Dietary Manager (ADM), several deficiencies were noted. In the dry storage area, multiple food items, including white rice, dinner rolls, stuffing, granulated sugar, bread crumbs, and yellow cake, were found open and without dates. Similarly, in the walk-in refrigerator, open packages of salad mix, pepperoni, cheddar cheese, tater tots, and catfish were found without dates. Additionally, the fryer was observed to be extremely dirty with brown oil, indicating that the oil had gone bad and was unsuitable for cooking. The ADM acknowledged the unsuitability of the fryer for food preparation. The facility's dietary close-down checklist and procedure for dating food items, which require all opened items to be labeled and dated, were not followed.
Inaccurate Medical Record Documentation for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident, identified as Resident #9. This resident was admitted with diagnoses including metabolic encephalopathy, heart failure, and Parkinson's disease, and was noted to be severely cognitively impaired, requiring assistance with activities of daily living. A review of the Minimum Data Set (MDS) 3.0 assessment indicated that the resident needed supervision for eating activities. However, discrepancies were found in the dietary notes, with concerns about weight accuracy due to hospitalization and diuretic medication effects. Despite these concerns, no additional dietary notations or assessments were recorded for November and December 2024. An interview with a Dietary Technician revealed that the technician had mistakenly documented another resident's nutritional information into Resident #9's medical record, leading to inaccuracies in the resident's medical documentation.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment and did not ensure that food and liquids were stored according to professional standards for food safety. During an inspection, surveyors observed wet and dry food debris covering the kitchen floor, a garbage receptacle with a lid covered in dry food debris, and a reach-in refrigerator with dried food and liquid debris on the shelving. Additionally, the coffee maker's dispensing spouts had caked-on dry liquid, and a five-gallon bucket near the dishwasher contained broken porcelain plates and was filled with fruit flies. These observations were confirmed by the Dietary Director, who then instructed the kitchen staff to begin cleaning the floor. Further inspection of the kitchen refrigerator revealed several undated containers of food, including strawberries, grapes, tomatoes, cucumbers, and opened milk containers, as well as an undated half-gallon of apple cider. Dietary Aides confirmed that some of these items were personal belongings of the staff. Despite having received training on kitchen sanitation and proper food storage, the staff failed to adhere to the facility's policy, which requires labeling ready-to-eat foods held for more than 24 hours and maintaining clean storage areas. This deficiency was investigated under Complaint Numbers OH00158730 and OH00157687.
Failure to Follow Menu and Portion Sizes
Penalty
Summary
The facility failed to adhere to the prescribed menu and portion sizes during meal service, affecting 29 residents on the east wing of the third floor. Observations on the specified date revealed that staff were serving country fried steak without the required gravy, as the dietary aide was unsure due to its absence on the meal ticket. The dietary director attempted to rectify the situation by instructing the aide to use a scoop with holes, but this was ineffective as the watery gravy ran through the holes, failing to cover the steak. Additionally, the chicken dumpling soup was served in smaller portions than specified, using a green scoop that provided only 4.5 ounces instead of the required eight ounces, resulting in bowls with mostly broth and little solid content. The deficiency was further compounded by the improper preparation of the brown gravy, as the staff used corn starch instead of flour due to unavailability, leading to a consistency that did not meet the recipe's requirements. Despite having received training on kitchen sanitation, food storage, meal preparation, and serving, the dietary staff were unable to follow the menu and recipes accurately. This non-compliance was investigated under Complaint Numbers OH00158730 and OH00157687, highlighting the facility's failure to meet the nutritional needs of its residents as per the established menu guidelines.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain appropriate and appetizing food temperatures, affecting 29 residents on the east wing of the third floor. Observations and interviews revealed that foods intended to be hot were served lukewarm or cool. Specifically, a test tray sampled by a wound nurse showed that the country fried steak was lukewarm and dry, with a temperature of 98 degrees Fahrenheit, while the potatoes and carrots were cool at 78 degrees Fahrenheit. This was confirmed by the wound nurse during the test tray sampling. The Dietary Director, who had been working at the facility for eight months, acknowledged that the kitchen staff were not effectively maintaining food temperatures. The facility had recently changed its serving procedures, which included plating food in the serveries on each floor and covering it with a lid, but they stopped using warming pallets. Despite staff training on proper food temperature maintenance, the facility's policies were not followed, as food should be held at 135 degrees Fahrenheit or higher, and served at 140 degrees Fahrenheit or above.
Failure to Follow Physician's Orders for Catheter Change
Penalty
Summary
The facility failed to follow the physician's orders for changing a resident's suprapubic catheter in a timely manner. The resident, who had multiple sclerosis and neuromuscular dysfunction of the bladder, had an order to change the catheter every 30 days on the evening shift and as needed for blockage. However, the Treatment Administration Record showed that the catheter was changed on 05/30/24 and 07/12/24, but there was no documentation of a change on 06/10/24, as claimed by a Licensed Practical Nurse (LPN). The LPN stated that the resident requested the catheter change to be moved to the dayshift, but there was no documentation to support this change or that the physician was informed. The resident contradicted the LPN's statement, indicating that she did not request the change to the dayshift and that the catheter was still being changed on the evening shift. She also mentioned that there were instances when the catheter was not changed as ordered. This discrepancy in catheter change documentation and adherence to physician orders led to the deficiency, which was investigated under a specific complaint number.
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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 Parma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant Lake Villa | 1.4 mi | ★★★★★ | 0 | 0 |
| Pleasantview Care Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Parma Care Center | 2.3 mi | ★★★★★ | 2 | 0 |
| Broadview Multi Care Center | 2.4 mi | ★★★★★ | 6 | 0 |
| Seven Hills Health & Rehab Center | 2.4 mi | ★★★★★ | 0 | 0 |
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