Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Ohman Family Living At Holly during CMS and state inspections, most recent first.
Surveyors found that three ventilator‑dependent residents with tracheostomies and complex respiratory conditions had numerous missing entries on Respiratory Treatment Records for ordered q6h ventilator checks, aerosol treatments (including albuterol, ipratropium‑albuterol, sodium chloride, and budesonide), trach assessments, trach care, inner cannula changes, oxygen administration/titration, and cough assist treatments. Care plans for these residents included oxygen therapy, trach care, and ventilator dependence with related interventions but did not specifically address the required q6h ventilator checks. The ADON, DON, RT staff, and Director of RT all verified the blanks, stated they believed treatments were done but not documented, confirmed the RTR was the only form used for ventilator checks, and acknowledged that documentation on the RTR was not accurate, despite a facility policy requiring medication error/omission reports when errors are discovered.
A resident with lumbar spondylosis, diabetes, hypertension, and documented self-care deficits, including frequent bowel and bladder incontinence and dependence with toileting, activated the call light for toileting assistance. The electronic call system showed the call light active and unanswered for an extended period while staff sat at the nurse’s station and did not respond. An agency CNA and the assigned LPN both heard the alarm but did not answer, with the LPN assuming aides would respond. Another CNA, passing by on the way to lunch, eventually entered the room, found the resident had become incontinent in bed due to the delay, and then provided toileting assistance, hygiene, and changed the urine-soiled bedding.
Failure to follow neutropenic precautions for a resident with myeloblastic leukemia. The resident had an order for transmission-based precautions requiring signage, N95 mask, gown, gloves, shield, hand hygiene, and masking outside the room, but staff used only surgical masks when entering the room, no N95 masks were available, and the resident was observed in common areas without a mask and in close contact with others. The DON confirmed the ordered precautions were not being followed.
A resident who was dependent on staff for transfers sustained a head injury and concussion when a Hoyer lift tipped and struck the resident during a transfer to bed. The incident occurred because the lift did not clear the raised bolsters of an air mattress, causing the lift to tip as two CNAs attempted the transfer. The resident required emergency care for a laceration and concussion. Staff interviews and documentation confirmed that the air mattress's design interfered with safe transfer procedures.
Incomplete Respiratory Treatment and Ventilator Documentation for Ventilator-Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and respiratory treatment documentation for three ventilator‑dependent residents with tracheostomies. For one resident with acute respiratory failure, sepsis, heart failure, tracheostomy, and ventilator dependence, the Respiratory Treatment Record (RTR) contained numerous blanks for ordered ventilator checks scheduled every six hours and as needed across multiple days in February and March. Additional blanks were found for ordered oxygen equipment changes, nebulized sodium chloride and budesonide treatments, ipratropium‑albuterol treatments, tracheostomy assessments each shift, tracheostomy care twice daily, daily inner cannula changes, oxygen administration and monitoring, tracheostomy collar setup changes, and cough assist treatments. The resident’s care plan included oxygen therapy, tracheostomy care, and ventilator dependence with related interventions, but did not include the specific intervention for ventilator checks every six hours. A second resident, also cognitively intact and dependent in ADLs with acute respiratory failure, heart failure, tracheostomy, and ventilator dependence, had similar documentation gaps. The RTR for this resident showed missing entries for ordered ventilator checks every six hours and as needed, as well as for scheduled albuterol nebulization treatments and sodium chloride nebulization treatments. There were also blanks for ordered tracheostomy cuff assessments every shift and oxygen orders intended to maintain oxygen saturation at or above 88 percent. The resident’s care plan documented oxygen therapy, ventilator dependence, and tracheostomy care with associated interventions such as administering medications and aerosol treatments as ordered, monitoring oxygen saturation, and assessing for signs of hypoxia, but did not address the specific requirement for ventilator checks every six hours. The third resident, with extensive diagnoses including acute and chronic respiratory failure, CHF, COPD, interstitial lung disease, dysphagia, myasthenia gravis, non‑Hodgkin lymphoma, dementia, and CKD, and who had a tracheostomy and was ventilator‑dependent, also had incomplete documentation. For this resident, the RTR contained multiple blanks for ordered ventilator checks every six hours and as needed, both before and after a hospital discharge and readmission. There were additional blanks for ordered albuterol nebulization and later ipratropium‑albuterol aerosol treatments, as well as for oxygen titration orders to maintain oxygen saturation of 88 percent or greater every shift. The care plan for this resident identified tracheostomy and ventilator dependence with interventions including aerosol treatments as ordered, suctioning as necessary, and monitoring and documenting respiratory status every shift. Interviews with the ADON and a respiratory therapist confirmed that an RT was always present in the facility and that RT staff were expected to document on the RTR when orders were completed, omitted, refused, or not completed for any reason. They verified the blanks on the RTRs for all three residents and stated they believed the orders were completed but not documented, and confirmed there was no other documentation used for ventilator checks beyond the RTR. The DON also verified the presence of blanks on the RTRs for ventilator checks, aerosol treatments, tracheostomy assessments, and oxygen orders, and stated that a medication error form should have been completed for any omitted treatment or medication. The Director of Respiratory Therapy acknowledged noticing the blanks, stated that RT staff were not used to documenting on the RTR and that she herself had not documented at times, and confirmed that the RTR documentation was not accurate. Facility policies on medication errors and invasive mechanical ventilation were reviewed; the medication error policy required completion of a medication error/omission report when an error was discovered, and the invasive mechanical ventilation policy did not address ventilator checks or documentation requirements on the RTR.
Untimely Response to Call Light Leads to Incontinence Episode
Penalty
Summary
The facility failed to provide timely incontinence and toileting care to Resident #2, who had diagnoses including lumbar spondylosis, diabetes, and hypertension, and was care planned for self-care deficits related to weakness and limited mobility. The resident’s care plan and MDS documented bladder incontinence, frequent bowel and bladder incontinence, dependence with toileting, and the need for staff assistance with hygiene and transfers, including one staff participation with toileting and checking the resident as required for incontinence. Despite these identified needs, the electronic call light system at the nurse’s station showed Resident #2’s call light active and unanswered for at least 35 minutes while two staff members were seated at the nurse’s station with the alarm sounding. When Resident #2 was observed and interviewed, she reported that she had activated the call light for toileting assistance. A CNA who was on her way to lunch entered the room approximately 45 minutes after the call light had been activated and found that the resident had already been incontinent in bed due to the delay. The CNA then assisted the resident into her wheelchair, to the bathroom, and with personal hygiene, and changed the urine-soiled bedding. Another agency CNA present at the nurse’s station acknowledged hearing the call system alarming but did not answer the call light. The LPN assigned to the resident also stated she heard the call light but assumed the aides would respond and was not aware which aide was assigned to that resident.
Failure to Follow Neutropenic Precautions
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained for a resident with myeloblastic leukemia who was ordered neutropenic transmission-based precautions. The resident was admitted with diagnoses including Cauda Equina Syndrome, myeloblastic leukemia, epileptic syndrome, diastolic heart failure, adult failure to thrive, depression, and venous thrombosis and embolism. The physician’s order dated 10/27/25 required signage outside the room, N95 mask, shield, gloves, and gown for anyone entering the room, removal of PPE before leaving the room, hand hygiene before and after entry, and sanitizing shared equipment between uses. The resident’s MDS showed a BIMS score of 14 out of 15, indicating cognitive intactness, and she required maximum assistance with showering and personal hygiene, was dependent for toileting and mobility, and was incontinent of bowel and bladder. Observation showed PPE hanging outside the room, including surgical masks, gowns, gloves, and hand sanitizer, but no N95 masks were available. The resident was later observed outside her room in the common area without a mask and in close contact with other residents and staff. An LPN was observed entering the room wearing only a surgical mask. The LPN stated the resident did not wear a mask outside her room and that staff wore surgical masks when entering the room but did not don all PPE unless providing care. The LPN also verified the order required an N95 mask, gown, gloves, and hand hygiene on entry and exit, and that the resident should wear a mask outside her room. The DON confirmed the order and stated the facility had not been using N95 masks as ordered and that the provider should have been contacted to change the order to surgical masks.
Resident Injured During Unsafe Hoyer Lift Transfer Due to Air Mattress Obstruction
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer for a resident who was dependent on staff for all transfers and required the use of a Hoyer lift. The resident, who had diagnoses including Parkinson's disease with dyskinesia, generalized muscle weakness, and chronic systolic heart failure, was being transferred from a wheelchair to bed using a Hoyer lift by two CNAs. The resident's care plan specified the use of a Hoyer lift with two staff and an air mattress with bolsters was in place on the bed as a pressure relief intervention. During the transfer, the Hoyer lift did not clear the raised bolsters of the air mattress. As the staff maneuvered the resident onto the bed, the lift tipped and the top-heavy part struck the resident on the head, resulting in a laceration and concussion. The incident was witnessed by the two CNAs performing the transfer, and the nurse on duty was called to assess the resident immediately after the injury occurred. The resident was transported to the emergency department, where he received six staples to close the wound and was diagnosed with a concussion. Interviews with staff revealed that the air mattress's height and bolsters interfered with the safe operation of the Hoyer lift, contributing to the tipping incident. The manufacturer's guidelines for the Hoyer lift warned of the risk of tipping and emphasized the need to keep the base widened for stability. The facility's policy required at least two staff for mechanical lift transfers and for staff to ensure resident safety and security during transfers. Despite these guidelines and policies, the transfer was not completed safely, resulting in actual harm to the resident.
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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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| Chardon Woods | 4.3 mi | ★★★★★ | 0 | 0 |
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| Chardon Center | 6.8 mi | ★★★★★ | 0 | 0 |
| The Laurels Of Chagrin Falls | 6.9 mi | ★★★★★ | 1 | 0 |
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