Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Wood Haven Health Care Senior Living & Rehab during CMS and state inspections, most recent first.
Failure to Monitor Psychotropic Medication Side Effects: Multiple residents with diagnoses including dementia, depression, anxiety, and psychotic disorders were prescribed psychotropic medications such as benzodiazepines, antipsychotics, and antidepressants. Although care plans identified risks for side effects and listed symptoms to observe, the MAR/TAR showed no routine monitoring for behaviors or adverse effects. Staff interviews confirmed the facility did not routinely monitor psychotropic medication side effects and had no clear charting location for these assessments.
Failure to monitor mechanical lift slings and Sara Steady stand assist devices led to use of worn, unlabeled slings and a resident fall when a seat cushion bolt broke during use. Staff gave conflicting accounts of who was responsible for sling checks, no documentation of sling integrity monitoring was available, and laundry staff observed frayed disposable slings hanging in the laundry area. The DON and Administrator also confirmed there was no assigned inspection process for the Sara Steady devices, despite a resident incident and manufacturer guidance for routine checks.
Mechanical Lift Slings Not Monitored or Inspected: Staff used multiple mechanical lift slings that were worn, frayed, discolored, or missing/readable tags during resident transfers. CNA, laundry, and DON interviews showed no clear responsibility for sling integrity checks and no documentation of monitoring, while manufacturer instructions required inspection before use and at least every 6 months. One resident also stated she felt nervous during lift transfers because she feared being dropped.
Incomplete Investigation of Alleged Abuse and Neglect: The facility failed to thoroughly investigate a spouse’s allegation of physical and mental abuse involving a resident with severe cognitive impairment and multiple diagnoses. Although the SRI was submitted, the investigation was limited to interviews with the POA and spouse; the identified staff were not placed on leave, no other residents or staff were interviewed, no skin assessments were completed, and no related staff education was provided.
Failure to Complete PASRR Level II After New Schizophrenia Diagnosis: A resident with Alzheimer’s disease, dementia, and psychotic disorder with hallucinations received a new schizophrenia diagnosis, but the facility did not complete the required PASRR level II. The record showed severe cognitive impairment, no anti-psychotic meds, and a care plan addressing schizophrenia; the SW confirmed the PASRR level II should have been completed but was not.
A resident with impaired cognition, diabetes, anxiety, anemia, and depression required total assistance with transfers and was to use a mechanical lift or Sara Steady for safe movement. During a two-person transfer, a seat cushion on the Sara Steady gave way and the resident fell, sustaining an abrasion to the right side. Interviews showed two separate Sara Steady devices had the same bolt issue, one had been welded earlier, and the devices were not being inspected by the third-party service company despite manufacturer guidance for monthly checks of fasteners, seat assemblies, and casters.
A resident with chronic respiratory failure, SOB, pulmonary HTN, and CHF was observed receiving oxygen at a higher flow rate than ordered. The resident’s care plan called for oxygen as ordered, but the flow was documented at 4.5 L/min and later at 4 L/min via NC when the order was for 2 to 3 L/min; an LPN verified the mismatch and adjusted the rate.
A resident with severe cognitive impairment and multiple diagnoses was documented in medical and dental assessments as having natural teeth with missing teeth and no dentures, while staff interviews revealed the resident actually had partial dentures. This inconsistency between staff knowledge and assessment documentation resulted in a deficiency related to inaccurate resident assessments.
A resident with multiple stage three pressure ulcers was not properly assessed when a Unit Manager documented wound measurements from a previous assessment without performing a new evaluation. This resulted in inaccurate documentation of the resident's wound status, contrary to the care plan requirements for weekly wound assessment and measurement.
A resident with a history of trauma was involved in an incident where another resident threatened them with a clenched fist, causing distress and preventing participation in activities. Despite the resident's reports, the facility failed to notify the DON or Administrator and did not report the incident to the state, violating their policy on abuse prevention.
The facility failed to report an incident of alleged abuse between two residents, where one resident with a history of aggressive behavior swung fists at another resident with a history of trauma. Despite the incident being documented by an activity aide, the DON and Administrator were not informed, and no report was made to the State. This represents non-compliance with the facility's abuse policy.
A resident with thyroid cancer was administered Gavreto despite orders to hold it while receiving antibiotics. The facility failed to verify and document the order to hold the medication, leading to a significant medication error.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects, and adverse effects for five residents reviewed for unnecessary medications. Resident #1 had diagnoses including end stage renal disease, gastrointestinal hemorrhage, COPD, type 2 diabetes mellitus, and major depressive disorder, and was ordered Xanax and duloxetine. Although the care plan identified a risk for psychotropic side effects and included monitoring interventions, the MAR and TAR for March 2026 showed no monitoring for side effects of psychotropic medications. Resident #11 was admitted with Alzheimer’s disease, dementia with behaviors, dementia with psychotic disturbances, anxiety, and depression, and had orders for lorazepam and risperidone. The care plan identified risks for side effects of psychotropic medications and listed multiple potential adverse effects to observe for, but the MAR and TAR were silent for any medication side effect monitoring. Resident #12 had diagnoses including Alzheimer’s, schizophrenia, anxiety, and psychotic disorder with hallucinations, and was prescribed Ativan, Zoloft, and Buspar. The quarterly MDS showed cognitive impairment and behaviors, and the care plan addressed psychotropic side effects, but the MAR and TAR for February, March, and April 2026 contained no orders or mechanism for monitoring behaviors or side effects. Resident #44 had diagnoses including polyneuropathy, hypoxemia, morbid obesity, rheumatic heart disease, major depressive disorder, and anxiety, and was ordered Zoloft, mirtazapine, and buspirone. Resident #62 had diagnoses including metabolic encephalopathy, psychotic disorder with delusions, anxiety, type 2 diabetes mellitus, hypertension, and dementia, and was ordered Zoloft and Nuplazid. For both residents, the care plans identified psychotropic medication risks, but the MAR and TAR for March 2026 showed no monitoring for side effects. Staff interviews confirmed the facility did not conduct routine monitoring for behaviors or psychotropic medication side effects, and staff stated there was no specific place in the electronic charting to verify such assessments. The facility policy titled Unnecessary Drugs stated each resident’s drug regimen should be reviewed on an ongoing basis with adequate monitoring for efficacy and adverse consequences.
Failure to Monitor Lift Slings and Stand Assist Devices
Penalty
Summary
The facility failed to ensure routine monitoring was implemented for mechanical lift slings and stand assist devices. During observation of a mechanical lift transfer for a resident, staff used a sling that was worn and no longer had a tag attached. The CNA involved confirmed the sling was worn and missing its tag, and both CNAs stated they were not aware of who was responsible for monitoring sling integrity. Staff interviews also showed conflicting understanding of who monitored the slings, with CNA staff, laundry staff, the DON, and the Administrator each describing different responsibilities and no documentation available for sling integrity monitoring. Laundry staff stated the mechanical lift slings were washed separately from residents’ clothing and air dried on a clothesline, and two light blue slings observed in the laundry area were worn, discolored, and frayed. The laundry supervisor verified those slings were labeled as disposable. The medical records and inventory specialist stated disposable slings came from transport, the hospital, or EMS, and that CNAs were expected to monitor them before each use; the facility also had 26 brand new slings in the medical supply room. The DON stated laundry staff were responsible for monitoring sling integrity, but also verified there was no documentation of sling monitoring and was unaware the facility was using disposable slings. The facility also failed to ensure the Sara Steady stand assist devices were monitored. An incident log showed a resident fell when the left seat cushion broke off a Sara Steady while in use. Maintenance staff acknowledged welding a broken left seat bolt on one device, and the maintenance manager later confirmed two separate Sara Steady devices had issues with the left seat cushion bolt. He stated the third-party company inspected and serviced mechanical lifts but did not inspect the Sara Steady devices, and he had not inspected the other two devices until after the issue was discussed. The Administrator confirmed no one was assigned to inspect the Sara Steady devices, while the manufacturer’s manual required monthly checks of fasteners, seat assemblies, and casters.
Mechanical Lift Slings Not Monitored or Inspected
Penalty
Summary
The facility failed to ensure mechanical lift slings were monitored and inspected according to manufacturer instructions. During observation, a mechanical lift transfer for Resident #83 was completed using a sling that was worn and no longer had a tag attached, and CNA staff confirmed the sling was worn. Staff interviews showed CNA staff were not aware of who was responsible for monitoring sling integrity, while laundry staff and the DON gave differing accounts about responsibility for inspection. The facility also had no documentation showing integrity monitoring for the slings. Additional observations identified multiple residents using slings that were worn, frayed, discolored, or had unreadable or missing tags. Resident #34’s sling at the bedside was being used for transfers and had worn, frayed straps. Resident #15’s sling had significant fraying and an unreadable tag. Resident #74’s sling was extremely worn, extremely frayed, and had an unreadable tag. Resident #23’s sling had no tag, worn straps, and fraying. Resident #3’s sling was identified as a disposable sling that had been washed and reused, with a worn tag whose words could not be read. Record review showed these residents required mechanical lift transfers due to conditions including muscle weakness, dementia, hemiplegia/hemiparesis, chronic respiratory failure with hypoxia, heart failure, paraplegia, and other diagnoses. The facility’s laundry process included washing slings separately and air drying them, and staff stated disposable slings were being used. Manufacturer instructions reviewed in the investigation stated slings must be inspected before use and at least every six months, and the facility policy stated damaged or improperly functioning lift equipment would not be used and staff would inspect equipment prior to each use.
Incomplete Investigation of Alleged Abuse and Neglect
Penalty
Summary
The facility failed to complete a thorough investigation after an allegation of verbal abuse and neglect was reported for a resident who had type two diabetes mellitus with diabetic polyneuropathy, depression, stroke, and dysphasia. The resident was admitted to hospice and later died in the facility. The quarterly MDS assessment showed a BIMS score of 5, indicating severely impaired cognition, and the resident required set up for eating, moderate assistance with toileting hygiene, bed transfers, and transfers. The facility submitted a self-reported incident after the resident’s spouse alleged physical and mental abuse by nursing staff before the resident’s death, but the allegation was not fully investigated. The investigation included one interview with the resident’s POA and two interviews with the spouse, but the facility did not place the three identified staff members on leave, did not interview other residents or staff, did not complete skin assessments, and did not provide staff education related to the allegation. The Administrator and DON confirmed the investigation was not thorough, and the DON stated she wished the incident had not been reported because she did not believe the abuse occurred. The facility policy required an immediate investigation with identification and interviews of all involved persons and complete documentation.
Failure to Complete PASRR Level II After New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) level II after a resident received a new diagnosis of schizophrenia. The resident was admitted on 01/31/24 and had diagnoses that included Alzheimer's disease, dementia, schizophrenia, psychotic disorder with hallucinations, anxiety, adult failure to thrive, and breast cancer. Review of the quarterly MDS showed severe cognitive impairment, a diagnosis of schizophrenia, and no anti-psychotic medications being administered. The care plan, initiated 06/25, addressed schizophrenia with interventions related to medication administration, monitoring mood and side effects, and notifying the physician if side effects occurred. An electronic communication dated 07/31/24 from the NP requested that schizophrenia be added to the resident's diagnosis list. The medical record contained no evidence that a PASRR level II was completed when schizophrenia was added. During interview, the Social Worker verified that the resident had a new diagnosis of schizophrenia in 07/31/24 and confirmed that a PASRR level II should have been completed, but was not completed for the resident. The facility policy stated that behavioral health services include PASRR screening as part of the comprehensive assessment process.
Failure to Inspect Stand Assist Equipment Led to Resident Fall
Penalty
Summary
The facility failed to maintain and inspect resident transfer equipment to ensure safe transfers for one resident who required extensive assistance with activities of daily living and transfers. The resident had type II diabetes mellitus, anxiety, anemia, depression, and impaired cognition with a BIMS score of 8. The care plan directed staff to use a mechanical lift or a stand assist device (Sara Steady) for safe transfers. During a two-person assisted transfer using the Sara Steady, the resident fell in his room when one of the seat cushions gave way. Staff documented that the Sara Steady was in front of the resident with a broken seat cushion, and the resident sustained an abrasion to the right lower quadrant measuring 12 cm by 10 cm. Interviews with maintenance staff and the maintenance manager revealed that two separate Sara Steady devices had issues with the same left seat cushion bolt, that one bolt had been welded on a device approximately two weeks earlier, and that the facility did not have the third-party lift service inspect the Sara Steady devices. The manufacturer manual required monthly checks of fasteners, seat assemblies, and casters for wear, damage, and secure attachment.
Incorrect Oxygen Flow Rate
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when oxygen was administered at the wrong rate for a resident who required oxygen therapy. Resident #15 had diagnoses including chronic respiratory failure, shortness of breath, pulmonary hypertension, and congestive heart failure. The resident’s MDS indicated she was cognitively intact and required oxygen therapy, and her care plan addressed respiratory status and difficulty breathing with an intervention to administer oxygen as ordered. The physician orders for Resident #15 directed oxygen at two to three liters per minute via nasal cannula, with later orders updated to two to four liters per minute. During observation, the resident was seen with oxygen running at four and a half liters per minute via nasal cannula, and on a later observation the oxygen was running at four liters per minute via nasal cannula. An LPN verified the oxygen was running at four liters per minute and confirmed the order was for two to three liters per minute, then adjusted the oxygen rate to the correct rate.
Failure to Complete Accurate Dental Assessments
Penalty
Summary
The facility failed to ensure accurate assessments were completed for a resident with multiple diagnoses, including psychotic disorder with delusions, Parkinson's disease, anxiety, depression, dementia, and neurocognitive disorder with Lewy bodies. Medical record review showed that nursing admission and dental assessments consistently documented the resident as having natural teeth with missing teeth and no dentures. However, during staff interviews, a CNA reported that the resident had partial dentures, which was confirmed by the unit manager upon review of the assessments. The Minimum Data Set (MDS) assessment also indicated the resident had no broken or loosely fitting dentures and no mouth or facial pain, discomfort, or difficulty chewing. This discrepancy between staff knowledge and documented assessments led to the deficiency.
Failure to Accurately Assess and Document Pressure Ulcers
Penalty
Summary
A resident with paraplegia was admitted with multiple stage three pressure ulcers and additional diagnoses including seborrheic dermatitis. The care plan included interventions such as administering treatments as ordered, use of a low air loss alternating pressure mattress, and weekly documentation of wound measurements and characteristics. Weekly skin assessments documented the size and condition of the wounds, with some wounds being measured together and noted to have moderate serosanguinous drainage. The care plan also required detailed weekly documentation of each area of skin breakdown. During an interview, the Unit Manager (UM) confirmed that wound rounds were conducted weekly with a nurse practitioner (NP), and that she was present during these rounds to record wound measurements. However, the UM admitted that on one occasion, she documented the same wound measurements from a previous assessment without remeasuring or reassessing the wounds herself. This failure to perform an independent assessment and accurate documentation of the resident's wounds constituted the deficiency identified in the report.
Failure to Protect Resident from Abuse and Inadequate Reporting
Penalty
Summary
The facility failed to ensure that residents were free from abuse, specifically affecting one resident who was involved in an incident with another resident. The affected resident, who had diagnoses including schizophrenia, psychosis, and congestive heart failure, was reported to have intact cognition and no documented behaviors. The resident's care plan noted a history of trauma with interventions to provide a safe space for expressing feelings. An incident occurred where another resident approached the affected resident with a clenched fist during an activity, causing distress. Despite the resident's reports of feeling threatened and unable to attend activities, the facility did not take appropriate action. Interviews revealed that the Activity Director was aware of the incident and that a letter was written by an Activity Aide and given to the Director of Nursing (DON). However, the DON and Administrator were not notified of the incident, and no report was made to the State of Ohio regarding the abuse. The facility's policy on abuse, neglect, and exploitation defines mental abuse to include threats of punishment or deprivation, which aligns with the resident's experience. This oversight represents a failure to protect the resident from mental abuse and to follow proper reporting procedures.
Failure to Report Alleged Abuse Between Residents
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents, which was identified during a survey. Resident #11, who has intellectual disabilities and a history of aggressive behavior, was involved in an incident with Resident #10, who has schizophrenia and a history of trauma. On 12/08/24, Resident #11 displayed aggressive behavior towards Resident #10 during an activity, swinging fists but not making contact. Despite Resident #10 reporting the incident and feeling threatened, the facility staff did not report the incident to the appropriate authorities. Interviews and record reviews revealed that the Activity Director was aware of the incident and that Activity Aide #105 had written a letter about it, which was supposedly given to the Director of Nursing (DON). However, the DON and the Administrator were not notified of the incident, and no report was made to the State of Ohio. The facility's policy on abuse, neglect, and exploitation defines mental abuse to include threats of punishment or deprivation, which aligns with the unreported incident. This oversight represents non-compliance as investigated under Complaint Number OH00160615.
Failure to Follow Medication Orders for Chemotherapy
Penalty
Summary
The facility failed to follow documented medication orders for a resident, leading to a significant medication error. The resident, who had thyroid cancer and was temporarily placed in the facility, was supposed to have their chemotherapy medication, Gavreto, held while receiving intravenous antibiotics for a urinary tract infection. Despite this, Gavreto was administered on one occasion and marked as refused or not administered on others without proper documentation or verification of the order to hold the medication. The resident's daughter had informed the staff that the oncologist ordered the medication to be held, but the facility staff did not verify this with the oncologist. The facility's policy requires medications to be administered as ordered by the physician and to report and document any refusals or adverse side effects. However, the staff failed to document the verbal order to hold the medication and did not contact the oncologist to verify the order. The Unit Manager attempted to contact the oncologist but did not receive a response, and a verbal order was given to hold the medication, which was not documented. This resulted in the resident receiving Gavreto when it should have been held, indicating a failure to adhere to the facility's medication administration policy.
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What surveyors actually found near you
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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 Bowling Green
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bowling Green Manor | 2.1 mi | ★★★★★ | 0 | 0 |
| Willows At Bowling Green The | 3 mi | ★★★★★ | 1 | 0 |
| Astoria Place Of Waterville | 9.8 mi | ★★★★★ | 31 | 1 |
| Ayden Healthcare Of Waterville | 9.8 mi | ★★★★★ | 34 | 0 |
| St Clare Commons | 10.5 mi | ★★★★★ | 14 | 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.