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Health Inspection Summary
Legacy Mentor
8200 Mentor Hills Drive
Mentor, OH 44060
(440) 256-1496

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Deficiency Category
Inspection Date:
9/19/22
Complaint Reporting Period:
3/1/24 - 2/28/25
Inspection Date:
9/13/19
Complaint Reporting Period:
3/1/23 - 2/29/24
Inspection Date:
8/16/18
Complaint Reporting Period:
3/1/22 - 2/28/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies220
Quality of Life and Care Deficiencies362
Infection Control Deficiencies111
Resident Assessment and Care Planning Deficiencies330
Nursing and Physician Services Deficiencies010
Resident Rights Deficiencies320
Nutrition and Dietary Deficiencies231
Pharmacy Service Deficiencies122
Environmental Deficiencies000
Administration Deficiencies010

Detailed result for inspection on 9/19/22
Date of last standard health inspection:9/19/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25
Date(s) of infection control inspection(s) between 3/1/24 - 2/28/25
Total number of Health Deficiencies for this nursing home:15
Average number of Health Deficiencies in Ohio:10.7
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

9/19/2210/25/22
2 - Minimal harm or potential for actual harm
Few

Protect each resident from the wrongful use of the resident's belongings or money.

9/19/2210/25/22
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

7/25/248/6/24
3 - Actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

7/25/248/6/24
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate dialysis care/services for a resident who requires such services.

9/19/2210/25/22
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

9/19/2210/25/22
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

7/25/248/6/24
2 - Minimal harm or potential for actual harm
Few

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

9/19/2210/25/22
2 - Minimal harm or potential for actual harm
Few

PASARR screening for Mental disorders or Intellectual Disabilities

9/19/2210/25/22
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Reasonably accommodate the needs and preferences of each resident.

9/19/2210/25/22
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

9/19/2210/25/22
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

9/19/2210/25/22
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

9/19/2210/25/22
2 - Minimal harm or potential for actual harm
Many

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

12/23/2412/30/24
2 - Minimal harm or potential for actual harm
Few
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

9/19/2210/25/22
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 9/13/19
Date of last standard health inspection:9/13/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24
Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24
No infection control inspections
Total number of Health Deficiencies for this nursing home:21
Average number of Health Deficiencies in Ohio:10.2
Average number of Health Deficiencies in the United States:9.4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

9/13/1912/10/19
2 - Minimal harm or potential for actual harm
Few

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

9/13/1911/20/19
2 - Minimal harm or potential for actual harm
Many
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide care and assistance to perform activities of daily living for any resident who is unable.

6/1/236/27/23
2 - Minimal harm or potential for actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

6/23/236/27/23
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

6/1/236/27/23
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate pain management for a resident who requires such services.

9/13/1911/20/19
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

9/13/1912/10/19
2 - Minimal harm or potential for actual harm
Few

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

6/1/236/27/23
2 - Minimal harm or potential for actual harm
Some
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

9/13/1911/20/19
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

9/13/1911/20/19
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

9/13/1911/20/19
2 - Minimal harm or potential for actual harm
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

6/1/236/27/23
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

9/13/1911/20/19
2 - Minimal harm or potential for actual harm
Many
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

9/13/1911/20/19
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

9/13/1910/28/19
1 - Potential for minimal harm
Many
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

9/13/1911/20/19
2 - Minimal harm or potential for actual harm
Many

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

9/13/1911/20/19
2 - Minimal harm or potential for actual harm
Few

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

9/13/1911/20/19
2 - Minimal harm or potential for actual harm
Many
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that residents are free from significant medication errors.

9/13/1911/20/19
2 - Minimal harm or potential for actual harm
Few

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

9/13/1911/20/19
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

9/13/1910/28/19
1 - Potential for minimal harm
Many

Detailed result for inspection on 8/16/18
Date of last standard health inspection:8/16/18Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23
No complaint inspections
Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23
No infection control inspections
Total number of Health Deficiencies for this nursing home:6
Average number of Health Deficiencies in Ohio:9.7
Average number of Health Deficiencies in the United States:8.7
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

8/16/189/12/18
2 - Minimal harm or potential for actual harm
Few

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

8/16/189/12/18
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

8/16/189/12/18
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

8/16/189/12/18
2 - Minimal harm or potential for actual harm
Many
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

8/16/189/12/18
2 - Minimal harm or potential for actual harm
Few

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

8/16/189/12/18
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

7/25/248/6/24
3 - Actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

7/25/248/6/24
2 - Minimal harm or potential for actual harm
Few

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

7/25/248/6/24
2 - Minimal harm or potential for actual harm
Few

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

12/23/2412/30/24
2 - Minimal harm or potential for actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

6/1/236/27/23
2 - Minimal harm or potential for actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

6/23/236/27/23
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

6/1/236/27/23
2 - Minimal harm or potential for actual harm
Few

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

6/1/236/27/23
2 - Minimal harm or potential for actual harm
Some

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

6/1/236/27/23
2 - Minimal harm or potential for actual harm
Few
Infection control inspection deficiencies in the past 3 years
This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years.
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