Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - 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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, record review and review of the facility policy, the facility failed to ensure the air
conditioning units were working properly and temperatures were monitored to keep comfortable air
temperatures for the residents. This affected four residents (Resident's #2, #11, #25, #31) who resided in
the older section of the facility, ten residents (Resident's #6, #10, #13, #16, #19, #22, #24, #27, #29, #30)
who resided in the secured memory nursing unit in the old area of the facility, and had the potential to affect
ten residents (Resident's #1, #2, #5, #7, #9, #15, #17, #21, #23, #31) who ate in the dining area. The facility
census was 33.
Findings include:
Review of the facility census revealed Resident #2, #11, #25, and #31 resided on the facility's older section
of the facility. Resident #6, #10, #13, #16, #19, #22, #27, #29, and #30 resided on the secured memory
care unit.
Review of a list of residents that use the facility front dining room revealed Resident #1, #2, #5, #7, #9, #15,
#17, #21, #23, #31 used the dining room.
Review of Resident #2's medical record revealed an admission date of 11/06/21 and diagnoses included
Huntington's Disease, major depressive disorder, and anxiety disorder.
Review of Resident #2's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed
Resident #2 had severe cognitive impairment.
Review of Resident #25's medical record revealed an admission date of 05/09/23 and diagnoses included
congestive heart failure, type two diabetes mellitus, and hypertensive heart disease with heart failure.
Review of Resident #25's admission MDS 3.0 assessment dated [DATE] revealed Resident #25's Brief
Interview for Mental Status was not assessed.
Review of Resident #31's medical record revealed an admission date of 01/14/22 and diagnoses included
fracture of left femur, anxiety disorder, and type two diabetes with diabetic polyneuropathy.
Review of Resident #31's admission MDS 3.0 assessment dated [DATE] revealed Resident #31's Brief
Interview for Mental Status was not assessed.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
366036
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366036
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Glendora Health Care Center
1552 North Honeytown Road
Wooster, OH 44691
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Interview on 07/06/23 at 8:23 A.M. of State Tested Nursing Assistant (STNA) #231 revealed she was
assisting residents in the dining area. STNA #231 stated there was no air conditioning in the facility. STNA
#231 stated for the past month and probably longer the air conditioning in the facility did not work.
Observation on 07/06/23 at 8:23 A.M. of the dining area revealed it felt very warm and humid while standing
still.
Interview on 07/06/23 at 8:24 A.M. of Resident #25 revealed he was sitting in his room in the nursing unit
close to the dining area. Resident #5 stated this whole section of the facility was too hot, it is the old section
of the facility and he was told the air conditioning was being worked on. Resident #25 stated it was terrible
the last few days because it was so hot. Resident #25 stated he told Maintenance Director (MD) #204 the
facility was too hot, and did not understand why he was not given a window air conditioning unit. Resident
#25 indicated he felt sick from the heat, and laid down because he had no energy. Resident #25 stated he
was not eating his normal portions of food due to the heat.
Observation on 07/06/23 at 8:24 A.M. of Resident #25 revealed he had a fan turned on in his room.
Resident #25 indicated he kept the door closed and the fan on to help with the heat.
Interview on 07/06/23 at 8:26 A.M. of STNA #221 revealed it had been horribly hot on the old side of the
building for a few days and we felt like we were going to pass out. STNA #221 stated the thermometer read
90 degrees Fahrenheit in the dining area one of the days. STNA #221 stated the air conditioning was totally
out since 06/30/23. STNA #221 stated she passed extra water with ice to help keep the residents hydrated
and cool.
Interview on 07/06/23 at 8:27 A.M. of Resident #31 revealed she resided in the old part of the facility and
was sitting in her room with a fan on. Resident #31 stated it was really hot in the facility the past few days,
she could not sleep, she did not feel well, she felt like she had no energy and could not do anything
because of it.
Interview on 07/06/23 at 8:34 A.M. of MD #204 revealed the air conditioning was turned off this morning
because the air conditioners were getting worked on. MD #204 stated the workers took the air conditioner
apart and left to get a needed part.
Interview on 07/06/23 at 9:20 A.M. of the Director of Nursing (DON) revealed the older side of the facility
had a different air conditioning system than the newer side of the facility. The DON stated she noticed it was
warm on the old side of the building, and stated I say that every day. The DON stated the old part of the
facility always had a temperature difference from the new area. The DON indicated she was not aware the
air conditioning was not working.
Observation on 07/06/23 at 10:10 A.M. of the outside area of the facility revealed two air conditioning unit
with rust on some of the panels and other panels laying on the ground in front of the air conditioner.
Observation of the inside area of the air conditioners revealed the air conditioners were not working.
Observation on 07/06/23 at 10:18 A.M. of Resident #2 revealed he was lying on his bed, and his room felt
very warm and humid. Resident #2 confirmed it was hot in his room, and stated it is always hot.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366036
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366036
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Glendora Health Care Center
1552 North Honeytown Road
Wooster, OH 44691
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Interview on 07/06/23 at 10:51 A.M. of Registered Nurse (RN) #219 revealed she was assigned to the
secured memory care nursing unit, which was located on the old side of the facility, and another nursing
unit located on the old side of the facility. RN #219 stated it was very hot over the weekend, and she was
dripping sweat she was so hot. RN #219 stated the air conditioner had not worked since 04/2023 and
probably did not work before that. RN #219 stated Resident's #10, #11 and #31 absolutely complained
about it being so hot. RN #219 stated the front room common area and dining area were very hot and had
been for about a week. RN #219 stated she told someone about the heat in the facility but she could not
remember who.
Interview on 07/06/23 at 11:21 A.M. of Activities Director (AD) #228 revealed she conducted activities in the
front room common area and the dining room, and both rooms were very warm. AD #228 stated she moved
activities from the dining room to the front room because of the heat on 07/05/23 and today (07/06/23). AD
#228 stated she did not notice what the temperature in the facility was, but it felt very warm.
Interview on 07/06/23 at 11:27 A.M. of MD #204 revealed the air conditioning company conducted routine
inspections of the heating and cooling systems of the facility twice a year. MD #204 stated during the spring
inspection one of the air conditioners needed an igniter replaced. MD #204 indicated the humidity was
really bad the past week and made it feel even warmer in the facility. MD #204 stated he did not monitor the
temperature of the facility and document the temperatures on paper or in the electronic system. MD #204
stated he did not notice what the temperature on the thermometer was. MD #204 stated he monitored the
temperature by walking around and feeling how warm it was, and staff made him aware of issues quickly.
MD #204 stated on 07/03/23 he arrived at the facility and was told it was hot on the old side of the facility,
he went to the old side, it felt warm and humid and he called the air conditioning company and set up
service for 07/05/23 or 07/06/23. MD #204 stated residents told him it was hot and humid in the facility, but
he did not remember which residents. MD #204 stated he installed a window air conditioning unit in
Resident #11's room on 07/03/23 because her visitor said her room was really hot. MD #204 stated
Resident #32 told him it was hot the same day he made the service call (07/03/23), but she already had a
fan and did not install a window air conditioning unit.
Interview on 07/06/23 at 12:29 P. M of RN #219 revealed she provided extra fluids, juice, popsicles, and
frozen treats for the residents to help keep them hydrated and cool.
Interview on 07/06/23 at 12:29 P.M. of Dietary Aide (DA) #230 revealed she was given permission to give
the residents popsicles, ice cream, juice, ice to help keep them cool and hydrated.
Observation on 07/06/23 at 12:35 P.M. of MD #204 revealed he checked the temperatures of the old side of
the facility with a temperature device gun. MD #204 checked the temperature in the dining room and the
exterior wall area was 83 degrees.
Interview on 07/06/23 at 1:32 P.M. of Air Conditioning Rep (ACR) #246 revealed the air conditioning units
were very old and had to be recharged because there was a micro leak in the system. ACR #246 stated
when the air conditioners stopped blowing cold air they needed recharged. ACR #246 stated the air
conditioning unit for the secured nursing unit needed replaced because it needed a part that was not
manufactured anymore. ACR #246 stated the facility would need to use supplemental air like window air
conditioning units in the secured memory care unit in the old area of the facility.
Observation on 07/06/23 at 1:44 P.M. of MD #204 revealed he checked the temperature in the dining
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366036
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366036
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Glendora Health Care Center
1552 North Honeytown Road
Wooster, OH 44691
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
room with a temperature device gun and the temperature in the exterior wall area was 82.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 07/06/23 at 2:56 P.M. with Air Conditioning Company Service Rep (ACCSR) #247 revealed
MD #204 called on 07/05/23 to set up appointment to have the air conditioners checked in the old side of
the facility. ACCSR #247 stated they were too busy on 07/05/23 to come to facility but arrived on 07/06/23.
Residents Affected - Some
Interview on 07/06/23 at 3:27 P.M. of the DON and the Administrator revealed today was when the DON
found out about the air conditioning not working. The DON stated yesterday MD #204 told her he called the
air conditioning company to come to the facility to check the air conditioning units. The DON stated she
received a text from STNA #221 on 07/01/23 about the old area of the facility being really hot. The DON
stated she contacted MD #204 on 07/01/23 at 2:30 P.M. to look into the heat issue. The DON stated she did
not work the weekend but worked on 07/01/23 and she did not feel the facility was excessively hot. The
DON stated no one said anything to her about the old area of the facility being very hot. The DON stated
she did not follow up with MD #204 about the reported heat level in the old area of the facility because she
did not hear anything else from him and she did not think it was a problem. The DON stated if there was an
issue MD #204 would bring it up in the morning meeting on 07/01/23, and he did not mention anything in
the meeting about the heat level in the old area of the facility. The Administrator stated she had been
helping another facility out and this was her first day in the facility this week.
Interview on 07/06/23 at 3:42 P.M. of MD #204 revealed he got a text on Saturday 07/02/23 from the DON
stating that it might be hot in the facility, and for him to check out the situation. MD #204 stated he installed
a window air conditioning unit by the secured memory unit nursing station due to the heat level on the unit.
MD #204 stated he reported that he installed window air conditioning units during the Monday (07/01/23)
morning meeting, and he called the air conditioning company Monday morning and spoke with the service
department to have someone come to facility to check out the air conditioning units. MD #204 stated this
was done by phone call, he did not send any emails, and there was no documentation of the call.
Review of the facility policy titled Safe and Homelike Environment undated included in accordance with
residents' rights, the facility would provide a safe, clean, comfortable and homelike environment. The facility
would maintain comfortable and safe temperature levels. The facility should strive to keep the temperature
in common resident areas between 71 and 81 degrees Fahrenheit.
This deficiency represents non-compliance investigated under Complaint Number OH00144257.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366036
If continuation sheet
Page 4 of 4
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F584 - Safe Environment
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.
FAQ · About this visit
Common questions about this visit
What happened during the July 6, 2023 survey of GLENDORA HEALTH CARE CENTER?
This was a inspection survey of GLENDORA HEALTH CARE CENTER on July 6, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GLENDORA HEALTH CARE CENTER on July 6, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.