Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ST MARY OF THE WOODS
AVON, OH · 50 certified beds · Last Life Safety survey August 13, 2026
CMS Certification Number 366342 · first certified May 2007
Ownership
Operated by SAINT THERESE SENIOR COMMUNITIES · Non profit - Corporation
- New ownershipOwnership changed December 1, 2024 (change of ownership)from ATRIUM RETIREMENT CENTERS LLC
Position within OH
10 citations — more than 23% of the 924 certified nursing homes in OH. Compared within OH rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier surveys on file averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens March 2028 — about 16 months from now. This facility’s last Life Safety survey was August 2026. Facilities in OH are typically surveyed 19–32 months after the last one (median 26), measured over 985 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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Emergency preparedness
2 of the 10 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 10 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 10 |
| Median facility in OH | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 23, 2022 | 5 |
| August 28, 2025 | 4 |
| August 13, 2026 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | 1 | 2025-08-28 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2022-06-23 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2025-08-28 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2022-06-23 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2026-08-13 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2025-08-28 |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | 1 | 2025-08-28 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2022-06-23 |
What the citations cover
- Smoke Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Emergency Preparedness Deficiencies 2
- Services Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 2 |
| Services Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 13, 2026 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (August 31, 2026) |
August 28, 2025 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (October 14, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (October 14, 2025) |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (October 14, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 14, 2025) |
June 23, 2022 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 15, 2022) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.