Deficiencies (last 4 years)
Deficiencies (over 4 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
211% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a November 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 1
Date: Nov 21, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to ensuring residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number 2656988.
Findings
The facility failed to ensure appropriate treatment and services to maintain or improve Resident #93's ability to carry out activities of daily living, specifically regarding safe transfers and use of assistive devices, resulting in a fall due to weak legs and knees buckling. Staff did not consistently use gait belts or walkers as recommended by physical therapy.
Deficiencies (1)
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Report Facts
Facility census: 75
Residents reviewed for falls: 3
Resident #93 BIMS score: 15
Resident #93 Fall Risk assessment score before fall: 4
Resident #93 Fall Risk assessment score after fall: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physical Therapist #300 | Physical Therapist | Verified staff should use a walker and gait belt when transferring Resident #93 |
| CNA #150 | Certified Nursing Assistant | Reported not using gait belt or walker when transferring Resident #93 |
| CNA #88 | Certified Nursing Assistant | Reported not using gait belt or walker when transferring Resident #93 |
| Director of Nursing | Director of Nursing (DON) | Verified gait belt use is standard of care but was not aware of PT recommendation for walker use for Resident #93 |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Date: Sep 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation focusing on infection prevention and control practices during medication administration.
Complaint Details
This deficiency was an incidental finding discovered during the complaint investigation.
Findings
The facility failed to perform hand hygiene during medication administration, affecting nine residents and potentially impacting all 28 residents on the Main Unit hallway. Observations and interviews confirmed that the nurse did not sanitize or wash hands between residents during medication administration.
Deficiencies (1)
Failure to perform hand hygiene during medication administration affecting multiple residents.
Report Facts
Residents affected: 9
Residents potentially affected: 28
Facility census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #234 | Named in hand hygiene deficiency during medication administration |
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 10
Date: May 5, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to care planning, activities of daily living, wound care, medication management, resident safety, food service, and antibiotic stewardship at Flint Ridge Nursing & Rehab Center.
Findings
The facility was found deficient in multiple areas including failure to complete baseline care plans timely, failure to hold care plan conferences, inadequate assistance with activities of daily living, inconsistent wound care treatment, lack of follow-up for contracture management, unsafe resident environment, failure to maintain therapeutic medication levels, improper food temperature and handling, and inadequate antibiotic use monitoring.
Deficiencies (10)
Failed to complete baseline care plans timely for residents #73 and #29.
Failed to hold care plan conferences for residents #18 and #53.
Failed to ensure timely activities of daily living assistance for Resident #14 and adequate fingernail care for Resident #38.
Failed to provide comprehensive wound care and missed multiple wound treatments for Resident #35's stage 4 pressure ulcer.
Failed to provide follow-up care and monitoring for Resident #38's contractured wrist, including lack of splinting after initial refusal.
Failed to ensure resident environment was free from accident hazards; unsafe bed setup for Resident #46.
Failed to obtain physician ordered laboratory studies to ensure therapeutic medication levels for Resident #17.
Failed to ensure meals were kept at appropriate temperatures while serving food, affecting Residents #35 and #61.
Failed to prepare, store, and serve food in a manner that prevents contamination.
Failed to ensure appropriate antibiotic use and monitoring for Resident #40.
Report Facts
Facility census: 76
Missed wound treatments: 10
Food temperature: 126.1
Food temperature: 118
Wrist contracture angle: 60
Wrist contracture angle: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #445 | Registered Nurse | Verified baseline care plan completion delay for Resident #73 |
| Director of Nursing | Director of Nursing (DON) | Confirmed baseline care plan not completed for Resident #29; acknowledged fingernail care issues for Resident #38; verified wound care documentation issues; unaware of unsafe bed setup for Resident #46; confirmed lab testing delay for Resident #17; confirmed antibiotic monitoring issues for Resident #40 |
| Social Services Director #410 | Social Services Director (SSD) | Confirmed lack of care conferences for Residents #18 and #53 |
| CNA #411 | Certified Nursing Assistant | Reported communication issue regarding Resident #14's wheelchair and resident's distress |
| RN #465 | Registered Nurse | Provided wound care details for Resident #35 |
| ADON #426 | Assistant Director of Nursing | Explained wound treatment changes and documentation requirements |
| Nurse Practitioner #621 | Nurse Practitioner | Provided clinical lead input on wound care for Resident #35 |
| Occupational Therapist #620 | Occupational Therapist | Confirmed splinting benefits and resident receptiveness for Resident #38 |
| LPN #431 | Licensed Practical Nurse | Unaware of purpose of triangular cushion under Resident #46's mattress |
| CNA #455 | Certified Nursing Assistant | Described use of triangular cushion to prevent Resident #46 from rolling out of bed |
| Dietary Manager #456 | Dietary Manager | Confirmed food temperature issues, food storage problems, and contamination concerns |
| Dietary Staff #533 | Dietary Staff | Observed food temperature check and improper glove use during food handling |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 14
Date: Sep 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of failure to provide dignified meal experiences, failure to provide written notice before room changes, unsafe environment in resident rooms, failure to provide assistance with meals, inadequate pressure ulcer care, unsafe oxygen transport and administration, severe weight loss due to inadequate nutritional interventions, failure to provide oxygen per physician orders, failure to provide appropriate pain management, failure to provide ordered serving sizes and whole milk, unsanitary kitchen conditions, and failure to maintain accurate medical records and infection control protocols.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00156069 and Master Complaint Number OH00156965.
Findings
The facility was found non-compliant in multiple areas including failure to provide dignified meal experiences, failure to notify residents of room changes, unsafe resident room conditions, inadequate assistance with meals, delayed and inadequate pressure ulcer care, unsafe oxygen handling and administration, failure to prevent severe weight loss due to delayed nutritional interventions, failure to provide oxygen as ordered, inadequate pain management, failure to provide ordered dietary items, unsanitary kitchen conditions, inaccurate medical records, and lapses in infection control practices.
Deficiencies (14)
Failed to provide a dignified meal experience affecting one resident (#24).
Failed to provide written notice before a resident's room was changed affecting one resident (#99).
Failed to ensure resident rooms were safe and accurately mapped affecting five residents (#67, #68, #73, #97, #99).
Failed to provide assistance with meals as needed affecting one resident (#37).
Failed to timely develop and implement effective pressure ulcer care for Resident #37.
Failed to ensure oxygen tanks were safely transported affecting two residents (#57, #89).
Failed to prevent severe weight loss and delayed nutritional interventions for Resident #2.
Failed to implement enteral feeding recommendations timely for Resident #2.
Failed to ensure residents received oxygen per physician orders affecting Resident #57.
Failed to provide ordered serving size and ensure whole milk was available for breakfast affecting seven residents (#19, #28, #41, #54, #71, #73, #83).
Failed to maintain a clean and sanitary kitchen.
Failed to maintain accurate medical records affecting three residents (#2, #28, #37).
Failed to ensure infection protocols were implemented during incontinence care and catheter care affecting two residents (#28, #37).
Failed to provide safe and appropriate pain management for Resident #37.
Report Facts
Census: 72
Weight loss percentage: 13.8
Weight loss percentage: 10.55
Weight loss in pounds: 13
Weight loss in pounds: 10.4
Weight loss in pounds: 20
Oxygen flow rate: 2
Oxygen flow rate: 3
Serving size: 3
Milk servings: 8
Balloon size: 10
Balloon size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #374 | State Tested Nurse Aide | Assisted residents with meals during dining room observation |
| STNA #330 | State Tested Nurse Aide | Brought Resident #24's meal tray into dining room |
| STNA #621 | State Tested Nurse Aide | Interviewed about meal service and assistance with Resident #24 and Resident #37 |
| Director of Nursing | Verified meal service policies, room change notices, pressure ulcer care, oxygen administration, nutritional interventions, and pain management | |
| Maintenance Director #326 | Maintenance Director | Verified unsafe room conditions and inaccurate facility maps |
| Nurse Practitioner #908 | Nurse Practitioner | Assessed Resident #37's pressure ulcers and pain |
| LPN #412 | Licensed Practical Nurse | Observed providing wound care and verified infection control lapses |
| RN #401 | Registered Nurse | Observed providing wound care and oxygen administration |
| STNA #416 | State Tested Nurse Aide | Observed transporting oxygen tanks and setting oxygen flow rate |
| Dietitian #924 | Registered Dietitian | Reviewed nutritional status and weight loss for Resident #2 |
| Dietary Aide #320 | Dietary Aide | Observed serving breakfast casserole and milk |
| Dietary Manager #415 | Dietary Manager | Verified kitchen cleanliness and equipment issues |
| Regional Maintenance Assistant #920 | Regional Maintenance Assistant | Verified kitchen cleanliness and requested estimate for new stove hood |
| Activity Aide #624 | Activity Aide | Observed Resident #28 with urinary catheter dragging on floor |
| STNA #358 | State Tested Nurse Aide | Raised and secured catheter tubing and bag for Resident #28 |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 4
Date: Jan 2, 2024
Visit Reason
The inspection was conducted as part of a complaint investigation (Complaint Number OH00148998 and OH00148925) concerning the accuracy of resident assessments, monitoring of antibiotic effectiveness, and medication administration practices.
Complaint Details
Complaint Number OH00148998 involved issues with skin injury assessment and antibiotic monitoring. Complaint Number OH00148925 involved medication administration errors and inaccurate medical record documentation.
Findings
The facility failed to ensure accurate admission assessments reflecting pre-existing skin injuries, failed to monitor vital signs for residents receiving antibiotics, and failed to administer thyroid medication at the scheduled time. Documentation inaccuracies in medical records were also identified.
Deficiencies (4)
Failed to ensure residents assessments were accurate to reflect a pre-existing skin injury during admission assessments.
Failed to ensure residents receiving antibiotics were monitored for effectiveness including obtaining and monitoring vital signs.
Failed to ensure residents thyroid medication was administered at the scheduled time.
Failed to ensure information documented in residents medical records were accurate to reflect care provided.
Report Facts
Facility census: 70
Levothyroxine dosage: 125
Levothyroxine lab result: 0.1
Antibiotic dosage: 500
Antibiotic administrations: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing #172 | Assistant Director of Nursing | Interviewed regarding Resident #141's skin injury and documentation |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident #141's skin injury assessment, antibiotic monitoring, and Resident #41's medication administration and documentation issues |
| Certified Nurse Practitioner #30 | Certified Nurse Practitioner | Made aware of pharmacist's recommendation to change Protonix administration time |
| Registered Nurse #150 | Registered Nurse | Created progress note regarding medication administration error and staff education |
Inspection Report
Routine
Census: 76
Deficiencies: 6
Date: Aug 17, 2023
Visit Reason
The inspection was conducted to review compliance with regulatory requirements related to resident care, including accuracy of Pre-admission Screening and Resident Review (PASRR) documents, notification of significant mental health changes, care plan revisions for advanced directives, nutrition management, and medication administration.
Findings
The facility failed to ensure PASRR documents accurately reflected resident diagnoses and medications, failed to notify the state mental health agency of significant changes, did not revise care plans to reflect changes in advanced directives, delayed implementation of dietary recommendations for weight loss, and administered medications outside physician-ordered parameters.
Deficiencies (6)
Failed to ensure resident PASRR documents accurately identified resident diagnoses and medications for Residents #5, #13, and #30.
Failed to notify the state mental health agency of significant mental health changes for Residents #5, #13, and #30.
Failed to revise Resident #7's care plan to reflect change in advanced directives from Full Code to DNR-CC-Arrest.
Failed to implement dietary recommendations in a timely manner for Resident #64 experiencing significant weight loss.
Administered blood pressure medications to Resident #30 outside of physician-ordered parameters.
Administered pain medication Norco to Resident #34 for pain levels outside of physician-ordered parameters.
Report Facts
Census: 76
Weight loss percentage: 10.5
Weight loss percentage: 3.8
Pain medication administrations outside parameters: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director #210 | Social Services Director | Interviewed regarding PASRR document accuracy and notification of mental health changes for Residents #5, #13, and #30 |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan revision for Resident #7, dietary recommendations and supplement orders for Resident #64, and medication administration for Residents #30 and #34 |
| Registered Dietitian #168 | Registered Dietitian | Interviewed regarding dietary services and weight loss management for Resident #64 |
| State Tested Nurse Aide #130 | State Tested Nurse Aide | Interviewed regarding observation of frozen supplement administration to Resident #64 |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 2
Date: Jun 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about advanced directives documentation and dietary supplement administration for Resident #56.
Complaint Details
This deficiency is cited as an incidental finding to Complaint Number OH00143297. The complaint involved concerns about advanced directive documentation and dietary supplement administration for Resident #56.
Findings
The facility failed to have clear documentation of advanced directives for Resident #56, who had conflicting physician orders for resuscitation status. Additionally, the facility failed to implement dietary supplement recommendations and did not administer dietary supplements as ordered, resulting in significant weight loss for the resident.
Deficiencies (2)
Failed to have clear documentation of advanced directives, with conflicting orders for full code and Do Not Resuscitate - Comfort Care for Resident #56.
Failed to implement dietary supplement recommendations and failed to administer dietary supplements as ordered for Resident #56, leading to significant weight loss.
Report Facts
Residents affected: 1
Census: 75
Weight loss percentage: 8.1
Missed supplement doses: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietitian #198 | Reported concerns about Resident #56 not receiving ordered supplements and communicated recommendations to nursing staff | |
| Director of Nursing | Verified conflicting advanced directive orders and failure to implement dietary supplement recommendations | |
| RN #116 | Registered Nurse | Aware of Resident #56's weight loss and decline, involved in communication about dietary recommendations |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 2
Date: Apr 21, 2023
Visit Reason
The inspection was conducted due to a complaint investigation (Complaint Number OH00141291) regarding food preparation and sanitary conditions at the facility.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00141291.
Findings
The facility failed to ensure food was prepared and served in a sanitary manner, potentially affecting 76 of 77 residents. Additionally, the facility failed to maintain a sanitary and comfortable environment, with various maintenance issues observed in multiple resident rooms affecting 22 residents.
Deficiencies (2)
Food was prepared and served in an unsanitary manner, including staff using gloved hands improperly without changing gloves or washing hands.
Facility failed to maintain a sanitary and comfortable environment, including cracked drywall, loose baseboards, chipped paint, holes in bathroom doors, worn flooring with stains, and scuffed wall railings in multiple resident rooms.
Report Facts
Residents affected by food preparation deficiency: 76
Residents affected by environmental deficiency: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager #212 | Verified observations regarding improper food handling |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Date: Feb 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation under Complaint Number OH00135186 regarding the facility's failure to timely and appropriately assess a significant weight change for Resident #68.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00135186.
Findings
The facility failed to document nutritional assessments or interventions for Resident #68 despite a significant unverified weight loss of 27.2 pounds. The Director of Nursing confirmed no reweigh or dietary notes were completed, and the plan of care identified nutritional risks without appropriate follow-up.
Deficiencies (1)
Failure to provide enough food/fluids to maintain a resident's health, specifically failure to timely and appropriately assess significant weight change for Resident #68.
Report Facts
Residents affected: 1
Facility census: 67
Weight change: 27.2
Weight measurements: 200
Weight measurement: 201
Weight measurement: 173.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding lack of reweigh and nutritional assessments for Resident #68 |
Inspection Report
Routine
Deficiencies: 16
Date: Jul 23, 2021
Visit Reason
The inspection was a routine survey of Flint Ridge Nursing & Rehab Center to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The survey identified multiple deficiencies including failure to maintain resident dignity, inadequate notification of physician regarding significant weight loss, privacy violations, incomplete resident assessments, failure to develop comprehensive care plans, inadequate personal care, failure to monitor and address pressure ulcers, unsafe smoking practices, failure to provide appropriate activities, failure to implement infection control precautions, and failure to ensure timely and appropriate medication management and laboratory testing.
Deficiencies (16)
Failure to promote Resident #311's dignity by not covering urinary drainage collection bag, visible to others.
Failure to notify physician of significant weight loss for Resident #19.
Failure to ensure residents (#5, #19, #212) were provided personal privacy; staff entered rooms without knocking and residents exposed to view.
Failure to comprehensively assess Resident #25's behavior patterns.
Failure to ensure Resident #32's assessment accurately reflected denture use.
Failure to refer Resident #7 for PASRR Level II assessment after new diagnosis of schizoaffective disorder following psychiatric hospitalization.
Failure to create a baseline plan of care addressing bruising and skin tears for Resident #59.
Failure to develop and implement comprehensive care plans for Residents #7, #25, #32, and #47.
Failure to provide timely and adequate personal care/shaving assistance to Residents #5 and #47.
Failure to adequately and comprehensively assess pressure ulcers for Residents #47 and #59 upon admission and/or re-admission.
Failure to ensure Resident #34's smoking area was free from hazards and provide adequate supervision to prevent accidents.
Failure to implement timely and effective interventions to ensure Resident #19 maintained acceptable nutritional status.
Failure to implement a comprehensive and individualized plan for Resident #11 with dementia to ensure appropriate treatment and services and to avoid unnecessary medication use.
Failure to ensure physician ordered laboratory testing was completed as ordered and physician was promptly notified of abnormal results for Residents #5 and #7.
Failure to ensure pharmacy recommendations for Residents #7 and #38 were addressed timely by the physician.
Failure to maintain acceptable infection control practices including proper PPE use for residents on droplet isolation and quarantine, affecting multiple residents.
Report Facts
Weight loss: 22.8
Pressure ulcer size: 18
Pressure ulcer size: 9
Pressure ulcer size: 1
Braden scale score: 13
Braden scale score: 11
BIMS score: 13
BIMS score: 11
BIMS score: 12
BIMS score: 2
BIMS score: 9
BIMS score: 0
INR level: 2.8
Hemoglobin A1c: 6.2
Medication administration count: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding failure to notify physician of weight loss, failure to update care plans, medication administration, and infection control |
| Administrator | Administrator | Interviewed regarding resident dignity and infection control PPE compliance |
| Social Service Director #43 | Social Service Director | Interviewed regarding PASRR referral, resident behavior assessments, and care plans |
| Activity Director #71 | Activity Director | Interviewed regarding activity provision for residents with dementia |
| Dietician | Dietician | Interviewed regarding nutritional supplement implementation for Resident #19 |
| Assistant Director of Nursing #38 | Assistant Director of Nursing | Interviewed regarding pharmacy recommendations and infection control |
| Licensed Practical Nurse #36 | Licensed Practical Nurse | Interviewed regarding smoking safety and PPE compliance |
| Maintenance Director #16 | Maintenance Director | Observed and interviewed regarding PPE compliance and smoking area safety |
| Registered Nurse #35 | Registered Nurse | Interviewed regarding resident hearing and vision issues |
| State Tested Nursing Assistant #79 | State Tested Nursing Assistant | Observed and interviewed regarding PPE compliance |
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