Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Ohman Family Living At Briar during CMS and state inspections, most recent first.
Infection control failures were observed involving a shared glucometer and two residents on precautions. A nurse used a glucometer for a resident with DM and severe cognitive impairment, but the device was not labeled and the facility stated it was shared on the unit; policy and manufacturer instructions required cleaning and disinfection between uses. An LPN entered the room of a resident with C. difficile without PPE and did not perform hand hygiene after leaving, despite contact precautions. A CNA also provided care to a resident with a tracheostomy, PEG tube, and Foley catheter without gown or gloves, despite EBP orders and facility policy requiring PPE for high-contact care.
A resident with multiple comorbidities, high fall risk, and orders for a Chorus or mechanical lift with two-person assistance experienced three witnessed falls or lowering-to-the-floor events when only one agency CNA attempted bed-to-wheelchair transfers using a Chorus lift. Documentation showed the resident was dependent for transfers and required two staff, yet single-staff transfers were performed, and in one incident the wheelchair was not locked, allowing it to move as the resident went to sit. The resident reported that aides did not lock the wheelchair and only one staff assisted each time, and facility leadership confirmed that two-person assistance was required but not followed. The facility’s falls policy addressed assessment and meetings but did not address monitoring to ensure that ordered transfer interventions were consistently implemented.
A facility failed to provide SNF ABNs to residents discharged from a Medicare Part A stay. Review of beneficiary notification records for three residents showed no documentation that the ABN was issued to the resident or representative, and an admin staff member confirmed that no SNF ABNs had been completed for residents discharged from Medicare Part A during the reviewed period.
Failure to Accommodate Resident’s Participation in Bingo: A cognitively intact resident with COPD, morbid obesity, borderline personality disorder, and legal blindness was unable to continue participating in bingo by phone from her room after staff stopped using personal cell phones for activities. The AD confirmed the resident had previously played bingo with staff assistance but no accommodation was put in place after staff were told to stop using personal phones, and the resident then stopped participating in activities despite bingo being scheduled multiple times.
Failure to provide ordered comfort measure for pain. A resident with lumbar radiculopathy, diabetic neuropathy, and CVA-related ADL deficits had frequent arm pain and an order for a left arm sling for comfort every shift. Although the TAR documented the sling as given, staff observations showed the resident was not wearing it during the day, and the resident said she had not yet received it. An LPN confirmed the sling was ordered for comfort.
Missing second signatures were found on the Controlled Medication Shift Change Log for one narcotic cart on a hall. During shift-change narcotic reconciliation, the log showed several entries without the required second nurse signature, and interviews with the LPN, RN, and ADON confirmed the omissions. The facility policy required a complete narcotic count at every shift change and two licensed nurses for wasted narcotics.
A resident’s MAR remained inaccurate after the g-tube was removed, with several medications still listed for g-tube administration even though the resident had been taking them orally. During med pass, an RN administered multiple meds by mouth and confirmed the route on the MAR was still incorrect; the resident and ADON both verified the tube had been discontinued and the record had not been updated.
A deficiency was cited after surveyors found one resident’s call light was not functioning and another resident’s call light was not within reach. One resident with intact cognition and significant care needs reported pressing the call button for help, but the hallway indicator was not activated. Another resident with MS, chronic respiratory failure, a trach, and total ADL dependence had a push pad call device placed on the chest instead of under the hand, and staff observed the resident could not activate it when asked.
Failure to Maintain a Sanitary Resident Room: A resident with DM2, hemiplegia, and bilateral heel pressure ulcers had white flakes from wound dressing changes scattered across the room floor, clothes, and bedding. The resident and an LPN confirmed the flakes were dead skin particles, but neither could say when the floor was last cleaned, despite the facility policy requiring resident room floors to be swept and mopped daily.
A resident with severe cognitive impairment alleged that an aide made a verbally abusive comment. Multiple staff members became aware of the allegation and conducted an internal investigation, but the incident was not reported to the state health department as required by policy and regulation. The DON confirmed the omission, resulting in a deficiency for failure to report suspected abuse.
The facility failed to thoroughly investigate an allegation of drug use by a staff member, potentially affecting all residents. The Administrator received a text message about a RN's drug use but only spoke to three staff members who denied any issues. No further investigation was conducted, and the RN, previously terminated for policy violations, was rehired with conditions that were not fully enforced. The facility's policy required a thorough investigation, which was not completed.
Infection Control Failures With Glucometer Cleaning and Precautions
Penalty
Summary
The facility failed to clean and disinfect a shared glucometer between residents. Resident #83 had diabetes mellitus type II, severe cognitive impairment, and orders for blood glucose checks and sliding-scale insulin. During observation of medication administration, one Assure Prism glucometer was found on the medication cart without a resident name. The RN stated it was the only glucometer on the unit for Resident #83’s use and cleaned it with an alcohol pad before entering the room, then cleaned it again after the blood sugar test. The RN also verified that Resident #83 was the only resident on the hall using that glucometer. The ADON stated glucometers are shared for blood testing and that CaviWipes1 are used to clean and disinfect the equipment between residents. The facility policy and manufacturer instructions required cleaning and disinfection of the device between uses. The facility also failed to follow contact precautions for Resident #5, who had C. difficile and was ordered on contact precautions. Resident #5 was cognitively intact, always incontinent of bowel, and had a positive stool sample for C. difficile. During observation, an agency LPN was in the resident’s room without PPE, opened a soda for the resident, exited the room, and did not wash her hands. The LPN acknowledged that the resident was in contact isolation for C. difficile but stated it was his last day. The facility policy required gloves and gown for interactions involving the resident or the resident’s environment and required PPE to be donned on room entry and removed before exiting. The facility further failed to follow enhanced barrier precautions for Resident #21. Resident #21 had diagnoses including chronic respiratory failure, chronic kidney disease stage three, dependence on a respirator, tracheostomy, PEG tube, and Foley catheter, and was cognitively intact. The care plan and orders identified the resident as requiring EBP related to the tracheostomy, PEG tube, and Foley catheter. During observation, a CNA entered the room and provided care with no gown or gloves on. The infection control nurse verified the observation. The facility policy stated that residents with indwelling medical devices such as a tracheostomy, urinary catheter, or feeding tube require EBP, including gown and glove use during high-contact care activities.
Failure to Provide Required Two-Person Assistance and Safe Technique During Lift Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and proper use of assistive devices during transfers for a resident who required a Chorus stand-up lift with two-person assistance. The resident had multiple diagnoses, including COPD, a Stage IV pressure ulcer, neuromuscular bladder, tremors, repeated falls, mild vascular dementia, and cognitive communication deficit, and was identified as high risk for falls. Physician orders, the Kardex, therapy documentation, and the MDS all indicated that the resident was dependent for transfers and required either a Chorus or mechanical lift with two staff assisting. Despite these orders and documented needs, the resident experienced three separate witnessed falls or lowering-to-the-floor events during transfers when only one agency CNA attempted to transfer him with the Chorus lift. On each occasion, the CNA attempted a bed-to-wheelchair transfer without a second staff member, and the resident was unable to maintain strength or balance, resulting in him being lowered to the floor. In one incident, the CNA did not lock the wheelchair, causing it to move back as the resident went to sit, contributing to the fall. Nursing notes and fall investigations documented that the resident lost strength in his upper extremities or could not maintain balance or footing while using the Chorus lift. Interviews confirmed that the resident reported falling three times because agency aides did not lock the wheelchair and only one staff member assisted him instead of two. The Director of Rehab and the DON verified that the resident always required two-staff assistance for both Chorus and mechanical lift transfers and that only one staff member had transferred him during the three incidents. The LPN on duty during all three events confirmed that each transfer was performed by a single agency CNA, that aides were expected to check the Kardex before providing care, and that one of the incidents was related to the wheelchair not being locked. Review of the facility’s falls prevention policy showed it addressed fall risk assessment and meetings but did not address monitoring to ensure that ordered interventions and care plan measures, such as required staff assistance levels, were implemented.
Failure to Issue SNF ABNs for Medicare Part A Discharges
Penalty
Summary
The facility failed to ensure Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) was issued to residents discharged from a Medicare Part A stay. Review of beneficiary notification records showed that for Resident #118, the last covered day of Medicare Part A service was 10/21/25, but the facility could not provide documentation that the SNF ABN was given to the resident or representative. Similar findings were identified for Resident #119, whose last covered day was 09/06/25, and Resident #120, whose last covered day was 11/26/25, with no documentation that the SNF ABN had been provided. During interview on 03/05/26 at 1:02 P.M., Administrative Personnel #357 confirmed that no SNF ABNs had been completed for residents discharged from a Medicare Part A stay from 09/04/25 to 03/04/26.
Failure to Accommodate Resident’s Participation in Bingo
Penalty
Summary
The facility failed to ensure accommodation was made for a cognitively intact resident with chronic obstructive pulmonary disease, morbid obesity, borderline personality disorder, and legal blindness to participate in an activity of choice. Resident #65 was dependent for toileting hygiene, showers, dressing, and personal hygiene, and reported that she had been banned from activities, which prevented her from continuing to play bingo telephonically from her bedroom with staff assistance for marking the bingo card. She stated it had been at least one month since she last played bingo. The Activity Director confirmed the resident had previously participated regularly in bingo with staff assistance but no longer did so after staff were no longer permitted to use personal cell phones for activities because the resident had contacted staff during off time using their personal numbers. The Activity Director stated she forgot about the resident and did not put any accommodations in place for her to play bingo. An activity staff member confirmed she had previously assisted the resident using her personal phone and was later told to block the resident from contacting her. Review of the January activity calendar showed bingo was scheduled multiple times, and the resident’s participation record showed she played bingo only twice in January and did not participate in any activities in February despite bingo being scheduled several times.
Failure to Provide Ordered Comfort Measure for Pain
Penalty
Summary
Safe, appropriate pain management was not provided for Resident #12, who was admitted with diagnoses including lumbar radiculopathy, type II diabetes with diabetic neuropathy, pain in the left ankle and joint, and pain in the right shoulder. The care plan documented that the resident suffered daily pain in the legs, toes, right shoulder, and neck, and included interventions for pain medications, assessing medication effectiveness, and monitoring for non-verbal signs of pain. The care plan did not include an intervention for an arm sling, although a later care plan entry noted a left arm sling for comfort related to an ADL self-care deficit from a CVA. The physician ordered a left arm sling for comfort every shift, and the treatment administration record documented that the sling was given during the day shift. However, observations on the same day at 8:40 A.M., 12:52 P.M., and 3:41 P.M. showed the resident was not wearing the sling as ordered or documented. During interview, the resident stated she had not yet been given an arm sling but was supposed to have it. An LPN stated the resident had frequent complaints of arm pain and that the sling was ordered for comfort. The facility pain management policy stated that pain interventions would be documented on the plan of care, MAR/TAR, and/or nurses notes, but it did not address non-pharmacological treatment interventions.
Missing second signatures on controlled medication shift change log
Penalty
Summary
The facility failed to ensure accurate records for the receipt and disposition of controlled drugs for one medication cart on the 400 Long Hall. During observation of the narcotic count reconciliation between the night shift LPN and the day shift RN, the Controlled Medication Shift Change Log was found to have missing second nurse signatures for 02/23/26, 02/24/26, 02/26/26, 03/02/26, and 03/03/26. The facility census was 92, and the deficiency was identified during review of the narcotic records for the cart. Review of the two-sided Controlled Medication Shift Change Log showed note additions and deletions on the reverse side, with discrepancies directed to be reported to nursing administration. The log required two signatures for each entry. Interviews with the LPN, RN, and ADON confirmed the missing signatures and verified that when a nurse accepted a new narcotic or destroyed a narcotic, a second nurse or nursing supervisor was to witness the receipt or disposal with a second signature. Review of the facility’s undated Dispensing and Narcotic Count Policy stated that a complete narcotic count must be performed at every shift change between the oncoming and outgoing nurse, and wasted narcotics must be performed by two licensed nurses.
Inaccurate Medication Route Documentation After G-Tube Removal
Penalty
Summary
The facility failed to maintain an accurate medical record for Resident #34, affecting one of five residents reviewed for medication orders. Resident #34 was admitted with diagnoses including hemiplegia, hemiparesis, dysarthria, type 2 diabetes mellitus, dysphagia, hypertension, major depressive disorder, insomnia, and anxiety disorder. The MDS admission assessment showed a BIMS score of 13, indicating intact cognition. A skilled nursing progress note dated 02/19/26 documented that the resident’s gastrostomy tube was removed by the physician that day. Review of the March 2026 order summary report and MAR showed multiple medications still ordered via g-tube, including Ambien, amlodipine, carvedilol, escitalopram, hydralazine, lisinopril, melatonin, and silodosin, while other medications were ordered orally. During observation of medication administration, an RN gave several of the g-tube-ordered medications orally and confirmed the MAR still listed the g-tube route even though the tube had been discontinued weeks earlier and the resident had been receiving medications by mouth. The resident also stated that the tube had been removed a long time ago. The ADON verified the g-tube orders remained on the March 2026 MAR and confirmed the facility procedure was to correct the orders in the electronic medical record so the MAR reflects the correct administration route.
Call Lights Not Functioning or Within Reach
Penalty
Summary
A deficiency was cited for failure to ensure a working call system was available in resident bathrooms and bathing areas, based on observations, interviews, record review, and facility policy review. The facility also failed to ensure a call light was functioning for one resident and failed to ensure another resident’s call light was within reach. The census was 92, and the findings involved two residents who were specifically investigated for call light concerns. Resident #26 was admitted with diagnoses including type II diabetes mellitus, chronic pain syndrome, hemiplegia and hemiparesis following cerebral infarction, PTSD, major depressive disorder, generalized anxiety disorder, insomnia, and Stage IV and Stage III pressure ulcers on the heels. The resident’s MDS showed a BIMS score of 14, indicating intact cognition, and documented substantial to maximum assistance needs for toileting, bathing, upper body dressing, and bed mobility, with dependence on a mechanical lift for safe transfers. During observation, the resident stated he had pressed his call light for help getting into his chair and to therapy, but no one was coming; he was holding and pressing the call button, yet the indicator light above the hallway door was not activated. Resident #3 was admitted with diagnoses including multiple sclerosis, chronic respiratory failure, type II diabetes mellitus, dependence on respirator ventilator, and muscle weakness. The resident’s MDS showed a BIMS score of 15 and dependence on staff for all ADLs, with bowel incontinence. The care plan identified a communication problem related to inability to speak due to a tracheostomy and directed that the call light be kept under her hand. However, multiple observations showed the push pad call light device positioned in the middle of the resident’s chest, and the resident was unable to activate it when asked. The spouse stated keeping the call light in reach was an issue, and staff verified the device placement before it was moved under the resident’s hand so she could activate it.
Failure to Maintain a Sanitary Resident Room
Penalty
Summary
The facility failed to provide a sanitary environment for Resident #26. The resident was admitted on 08/05/25 and had diagnoses including diabetes mellitus type II, chronic pain syndrome, hemiplegia and hemiparesis following cerebral infarction, Stage IV pressure ulcer of the left heel, Stage III pressure ulcer of the right heel, PTSD, major depressive disorder, generalized anxiety disorder, and insomnia. The resident’s MDS showed a BIMS score of 14, indicating intact cognition, and that he required assistance with oral hygiene, eating, toileting, bathing, dressing, personal hygiene, bed mobility, and mechanical lift transfers. During observation at the resident’s bedside, small white flakes were seen all over the floor. The resident stated the flakes were dead skin particles from daily dressing changes to wounds on both heels, and this was confirmed by an LPN. The LPN and resident were unable to say when the room floor was last cleaned or mopped. On a later observation, the resident stated there were more flakes of dry skin after that morning’s dressing changes and expressed frustration that the dry skin ended up on his clothes, bedding, and floor; he again stated he was unsure when the floor was last swept or mopped. The facility’s housekeeping policy stated resident room floors are to be swept and mopped daily.
Failure to Report Alleged Verbal Abuse to State Authorities
Penalty
Summary
An allegation of verbal abuse involving a resident with severe cognitive impairment, schizoaffective disorder, malnutrition, epilepsy, and dementia was not reported as required by facility policy and state regulations. The resident, who required staff assistance for all activities of daily living and had poor memory, attention, and judgment, reported to staff that an aide asked her why she was still breathing. Multiple staff members, including LPNs and a CNA, became aware of the allegation through direct communication with the resident and each other. The incident was discussed among staff, and statements were collected, but the aide in question could not be definitively identified by the resident, and other residents denied witnessing or experiencing similar abuse. Despite the facility's internal investigation into the allegation, the Director of Nursing confirmed that the incident was not reported to the Ohio Department of Health and no Self-Reported Incident Form was submitted, as required by both facility policy and state regulations. Review of the facility's policy indicated that all allegations of abuse must be immediately reported to the Administrator and the state agency. The failure to report the allegation externally constituted non-compliance with regulatory requirements.
Failure to Investigate Alleged Drug Use by Staff
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of drug use by a staff member, which had the potential to affect all residents. The Administrator received a text message alleging that a Registered Nurse (RN) was using drugs. However, the Administrator only spoke to three staff members, including the Clinical Manager, Staff Development Coordinator, and the Assistant Director of Nursing, who denied any issues with the RN or narcotic counts. No further actions were taken to investigate the allegation, such as interviewing direct care staff, residents, or reviewing narcotic count sheets and destruction logs. The RN in question had previously been suspended and then terminated for violating the narcotic destruction process policy, asking a staff member to falsify documents, and exercising poor nursing judgment. Despite this, the RN was rehired with conditions, including random drug screening and having three staff present during narcotic destruction. However, the frequency of the drug screenings was not specified, and only two screenings were conducted. The facility's policy required narcotics to be destroyed in the presence of two licensed nurses, but the destruction logs showed inconsistencies, with two additional staff signing without a date or time. The facility's policy also required a thorough investigation of suspected staff, which was not completed in this case.
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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 Middlefield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Burton Health Care Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Autumn Hills Healthcare Community | 4.6 mi | ★★★★★ | 3 | 0 |
| Chardon Woods | 8.9 mi | ★★★★★ | 0 | 0 |
| Mapleview Country Villa | 9.1 mi | ★★★★★ | 4 | 0 |
| Ohman Family Living At Holly | 10.6 mi | ★★★★★ | 7 | 0 |
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