Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

MT ALVERNA HOME INC

PARMA, OH · 153 certified beds · Last Life Safety survey December 12, 2024

CMS Certification Number 366071 · first certified August 1996

Ownership

Operated by FRANCISCAN COMMUNITIES · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within OH

41 citations — more than 97% of the 922 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

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 9 citations; the earlier surveys in the window averaged 16. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: August 2026 to August 2027. This facility’s last Life Safety survey was December 2024. Facilities in OH are typically surveyed 20–32 months after the last one (median 26), measured over 889 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 three years in Maryland. How the window is measured

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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

13 of the 41 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)

3 physical-environment citations 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 41 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	41
Median facility in OH	16
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
July 18, 2019	27
June 9, 2022	5
December 12, 2024	9

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	3	2024-12-12
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2024-12-12
K-0363	Install corridor and hallway doors that block smoke.	2	2022-06-09
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	2	2024-12-12
K-0351	Install an approved automatic sprinkler system.	2	2024-12-12
K-0911	Meet requirements for the installation and maintenance of electrical systems.	1	2019-07-18
E-0037	Establish staff and initial training requirements.	1	2019-07-18
E-0007	Address patient/client population and determine types of services needed.	1	2019-07-18

What the citations cover

Citations by CMS category

Smoke Deficiencies 16
Emergency Preparedness Deficiencies 13
Services Deficiencies 4
Gas, Vacuum, and Electrical Systems Deficiencies 3
Other 5

Citations by CMS category
Category	Citations
Smoke Deficiencies	16
Emergency Preparedness Deficiencies	13
Services Deficiencies	4
Gas, Vacuum, and Electrical Systems Deficiencies	3
Egress Deficiencies	3
Miscellaneous Deficiencies	1
Construction Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

December 12, 2024 — 9 citations

Citations issued on December 12, 2024
Tag	What the surveyor checks	Status
K-0311	Have an enclosure around a vertical opening shaft.	Deficient, Provider has date of correction (January 31, 2025)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (January 31, 2025)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (January 31, 2025)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (January 31, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (January 31, 2025)
K-0500	Meet other general requirements that are deficient.	Deficient, Provider has date of correction (January 31, 2025)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (January 31, 2025)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (January 31, 2025)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (January 31, 2025)

June 9, 2022 — 5 citations

Citations issued on June 9, 2022
Tag	What the surveyor checks	Status
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (July 15, 2022)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (July 15, 2022)
K-0362	Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.	Deficient, Provider has date of correction (July 15, 2022)
K-0363	Install corridor and hallway doors that block smoke.	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)

July 18, 2019 — 27 citations

Citations issued on July 18, 2019
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has plan of correction
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has plan of correction
E-0013	Develop Emergency Preparedness policies and procedures.	Deficient, Provider has plan of correction
E-0018	Establish procedures for tracking staff and patients during an emergency.	Deficient, Provider has plan of correction
E-0020	Establish policies and procedures including evacuation.	Deficient, Provider has plan of correction
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has plan of correction
E-0026	Establish roles under a Waiver declared by secretary.	Deficient, Provider has plan of correction
E-0029	Develop a communication plan.	Deficient, Provider has plan of correction
E-0030	List the names and contact information of those in the facility.	Deficient, Provider has plan of correction
E-0031	Provide emergency officials' contact information.	Deficient, Provider has plan of correction
E-0034	Provide a means of sharing information on occupancy/needs.	Deficient, Provider has plan of correction
E-0036	Establish emergency prep training and testing.	Deficient, Provider has plan of correction
E-0037	Establish staff and initial training requirements.	Deficient, Provider has plan of correction
K-0131	Meet requirements for sections of health care facilities separated by fire resistive construction.	Deficient, Provider has plan of correction
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (October 9, 2019)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (October 9, 2019)
K-0227	Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.	Deficient, Provider has date of correction (October 9, 2019)
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 9, 2019)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has plan of correction
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (October 9, 2019)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (October 9, 2019)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (October 9, 2019)
K-0363	Install corridor and hallway doors that block smoke.	Waiver has been granted (October 25, 2019)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (October 9, 2019)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (October 9, 2019)
K-0911	Meet requirements for the installation and maintenance of electrical systems.	Deficient, Provider has date of correction (October 9, 2019)
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 (October 9, 2019)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.