Deficiencies (last 5 years)
Deficiencies (over 5 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
28 residents
Based on a August 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 3
Date: Aug 27, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of failure to provide timely treatment following a resident's fall, failure to prevent pressure ulcers, and failure to provide timely incontinence care.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to provide timely treatment after a resident's fall, failed to prevent pressure ulcers, and failed to provide timely incontinence care. The investigation found substantiated deficiencies related to these issues.
Findings
The facility failed to provide timely treatment for a resident who experienced an unwitnessed fall resulting in a broken hip, failed to prevent the development of a pressure ulcer in another resident, and failed to implement timely interventions to address incontinence in a third resident. These deficiencies resulted in actual harm or potential for harm to residents.
Deficiencies (3)
Failure to provide timely treatment including notifying the physician and obtaining an x-ray after a resident's unwitnessed fall resulting in a broken hip.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failure to provide appropriate care for residents who are continent or incontinent of bowel/bladder, including timely incontinence care to prevent urinary tract infections.
Report Facts
Facility census: 28
Days delay for x-ray after fall: 9
Pressure sore size: 6.2
Pressure sore size: 5
Residents reviewed for change in condition: 3
Residents reviewed for pressure ulcers: 3
Residents reviewed for timely care and treatment: 4
Resident #30 admission date: 2024
Resident #30 discharge date: 2025
Resident #31 admission date: 2025
Resident #31 discharge date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager #131 | Unit Manager | Interviewed regarding delay in imaging and follow-up care for Resident #30 |
| Licensed Practical Nurse #111 | Licensed Practical Nurse | Hospice nurse who initially assessed Resident #30 after fall |
| Hospice Nurse Practitioner #202 | Hospice Nurse Practitioner | Declined ordering an x-ray initially for Resident #30 and consulted on care |
| Unit Manager #113 | Unit Manager | Interviewed regarding offloading orders and pressure ulcer care for Resident #31 |
| Division Manager of Quality and Compliance #203 | Division Manager of Quality and Compliance | Interviewed regarding pressure ulcer care and facility policies |
| Administrator | Administrator | Verified physician orders and care plans related to pressure ulcer prevention for Resident #31 |
| Licensed Practical Nurse Unit Manager #300 | Licensed Practical Nurse Unit Manager | Observed Resident #11 heavily soiled and confirmed incontinence care issues |
| Certified Nurse Aide #200 | Certified Nurse Aide | Interviewed regarding incontinence care and resident checks for Resident #11 |
| Licensed Practical Nurse #301 | Licensed Practical Nurse | Interviewed regarding awareness of Resident #11's incontinence status |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 3
Date: Apr 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation (Complaint Number OH00152129) regarding the facility's failure to provide appropriate catheter care and documentation as ordered by physicians.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00152129.
Findings
The facility failed to ensure treatment of a suprapubic catheter was provided per physician orders and failed to document urine output as required. Additionally, the facility failed to implement enhanced barrier precautions during catheter care for two residents with indwelling catheters.
Deficiencies (3)
Failure to provide suprapubic catheter care per physician orders including application of bacitracin ointment and use of split gauze.
Failure to document urine output every shift as ordered for Resident #20.
Failure to implement enhanced barrier precautions (gown and gloves) during catheter care for residents with indwelling catheters.
Report Facts
Facility census: 37
Urine volume: 245
Dates with no urine output recorded: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #75 | Observed catheter care for Resident #22 and admitted not applying bacitracin ointment or split gauze as ordered | |
| Unit Manager #76 | Verified current orders and enhanced barrier precautions required for catheter care | |
| State Tested Nursing Assistant (STNA) #77 | Observed catheter care for Resident #20 and did not wear gown as required | |
| Registered Nurse (RN) | Verified personal protective equipment needed for catheter care included gloves and gown |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 2
Date: Oct 31, 2023
Visit Reason
The inspection was conducted due to a complaint investigation (Complaint Number OH00146963) regarding the facility's failure to notify the physician and resident representative of a significant weight loss for Resident #3.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00146963.
Findings
The facility failed to notify the physician, dietician, and resident representative about Resident #3's significant weight loss of approximately 15.2 pounds (8.5%). Additionally, the facility did not ensure physician orders for a nutritional supplement were followed due to supplier issues, resulting in actual harm to the resident. Documentation and communication failures were confirmed through medical record reviews and staff interviews.
Deficiencies (2)
Failed to notify the physician and resident representative of significant weight loss for Resident #3.
Failed to ensure physician orders for nutritional supplement were followed and failed to notify physician and dietician of significant weight loss, resulting in actual harm.
Report Facts
Weight loss: 15.2
Census: 28
Weight loss percentage: 8.5
Weight loss percentage: 5.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #120 | Physician | Notified she was not informed of Resident #3's significant weight loss or supplement supply issues. |
| Licensed Practical Nurse #100 | Licensed Practical Nurse (LPN) | Verified no documentation of notification about significant weight loss in nurse's notes. |
| Licensed Practical Nurse #103 | Licensed Practical Nurse (LPN) | Stated Resident #3 receives Muscle Milk supplement supplied by family and Ensure supplement when waiting for more. |
| Registered Dietician #108 | Registered Dietician (RD) | Notified she was not aware of significant weight loss or supplier issues with Muscle Milk. |
| Central Supply Clerk #107 | Central Supply Clerk (CSC) | Reported supplier issues obtaining Muscle Milk and attempts to source supplement without authority to order alternatives. |
Inspection Report
Routine
Census: 31
Deficiencies: 8
Date: May 4, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Ohio Living Swan Creek nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare Non-Coverage notices, inadequate communication interventions for a resident with hearing impairment, lack of interventions for lower extremity edema, improper pressure ulcer care, insufficient fall prevention measures, inadequate incontinence care, failure to provide ordered nutrition, and unsanitary conditions in the shared shower room.
Deficiencies (8)
Failed to ensure Notice of Medicare Non-Coverage was provided when Medicare Part A services ended and a resident remained in the facility.
Failed to ensure communication interventions were provided and available for use to increase communication abilities of a resident with impaired hearing.
Failed to ensure monitoring and interventions were implemented to promote the management of lower extremity edema.
Failed to ensure interventions were maintained to promote intact skin integrity and prevent pressure ulcers.
Failed to ensure fall prevention interventions were provided in accordance with physician orders and care plan.
Failed to ensure a resident received timely and proper incontinence care.
Failed to follow physician orders to provide a meal for a resident reviewed for nutrition.
Failed to ensure the shared resident shower was maintained in a clean and sanitary manner.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 29
Facility census: 31
Falls: 222
Urinary tract infection colony count: 100000
Tube feeding volume: 240
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #504 | Social Worker | Confirmed facility did not provide Notice of Medicare Non-Coverage |
| Licensed Practical Nurse #498 | Licensed Practical Nurse | Interviewed regarding communication interventions, fall prevention, and incontinence care |
| Speech Language Pathologist #500 | Speech Language Pathologist | Provided skilled speech therapy and communication interventions for Resident #10 |
| Director of Nursing | Director of Nursing | Confirmed lack of edema interventions, fall prevention orders, and air mattress monitoring |
| Unit Manager #505 | Unit Manager | Verified chair alarm issues and fall prevention interventions |
| State Tested Nurse Aide #464 | State Tested Nurse Aide | Observed transferring Resident #23 and unaware of two-staff transfer requirement |
| Licensed Practical Nurse #403 | Licensed Practical Nurse | Discussed Resident #17 fall history and chair alarm use |
| State Tested Nurse Aide #464 | State Tested Nurse Aide | Observed providing incontinence care without perineal care for Resident #23 |
| Housekeeper #535 | Housekeeper | Verified persistent mildew in shared shower room |
| Licensed Practical Nurse #499 | Licensed Practical Nurse | Observed chair alarm disconnected on Resident #17's wheelchair |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Date: Jan 30, 2020
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to provide written notice of bed hold policy to residents transferred to hospitals and to review the rationale for as needed psychoactive medication orders extending beyond 14 days.
Complaint Details
The complaint investigation revealed that the facility did not provide written notice of bed hold policy to Resident #20 and their representative at the time of hospital transfers on two occasions. The facility also failed to provide a rationale for extending an as needed Ativan order beyond 14 days for Resident #3. Interviews confirmed these findings.
Findings
The facility failed to issue written notice of bed hold policy to residents and their representatives upon hospital transfer, affecting one resident. Additionally, the facility failed to provide rationale for an as needed psychoactive medication order extending beyond 14 days for one resident. The census was 33 residents.
Deficiencies (2)
Failed to issue a written notice of bed hold policy to residents and resident representatives when transferred from the facility.
Failed to provide rationale for an as needed psychoactive medication order extending beyond 14 days.
Report Facts
Residents affected: 1
Residents affected: 1
Residents reviewed for unnecessary medications: 5
Residents who received antianxiety medications: 6
Residents transferred to hospital: 6
Census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Admission Coordinator #250 | Interviewed regarding bed hold policy notification practices | |
| Director of Nursing | Interviewed regarding medication order rationale and stop date |
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 2
Date: Nov 15, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, quality assurance, and dining assistance in the nursing home.
Findings
The facility failed to provide a dignified dining experience for residents requiring assistance, specifically Resident #4 who was not assisted or encouraged to use utensils. Additionally, the facility failed to ensure required attendance of the Director of Nursing and Medical Director at quarterly Quality Assessment and Assurance Committee meetings.
Deficiencies (2)
Failed to provide a dignified dining experience for residents requiring assistance with eating, affecting Resident #4 who was not assisted or encouraged to use utensils.
Failed to ensure the Director of Nursing and Medical Director or designee attended the Quality Assessment and Assurance Committee meetings at least quarterly.
Report Facts
Residents affected: 29
Residents affected: 1
Residents requiring staff assistance with eating: 9
QAA Committee meetings: 4
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