Phoenix Of Fairlawn
120 Brookmont Rd, Akron, OH 44333 · For profit - Limited Liability company · 80 certified beds · (330) 666-7373 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.3% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 3.5% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.5% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 8.8% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.6% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.6% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 28.4% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 84.2% | 94.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 6.9% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.8% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.0% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.5% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 37.3% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 33.9% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.3% | 12.9% | 12.0% | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 35.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 20 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 31% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.7%CMS range 7.1–17.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 35.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 40.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 25.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 90.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 80 beds and averages 55.8 residents a day — about 70% occupied, or roughly 24 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.13 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.79 hrs/resident/day on weekends vs 4.27 on weekdays — 11% thinner on weekends. RN hours go from 0.55 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · G2022-10-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure care planned interventions were in place to prevent falls for Resident #11, Resident #53, Resident #37 and Resident #20. Actual harm occurred when Resident #11 and Resident #53 suffered a fall with a fracture nose and right femur respectively and were admitted to the hospital. This affected four residents (Resident #11, Resident #20, Resident #37, and Resident #53) out of six residents reviewed for falls. The facility census was 57. Findings include: 1. Resident #53 was admitted on [DATE] with diagnoses including malnutrition, chronic obstructive pulmonary disease, dementia with behaviors, delusional disturbances, iron deficiency anemia, constipation, aortic valve stenosis, congestive heart failure, fracture of the right femur, asthma, unsteadiness, difficulty walking and muscle weakness. Review of Resident #53's Minimum Data Set (MDS) assessment dated [DATE] revealed he needed extensive assistance of two staff members for bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-28 · tag F0926 — failed to keep the home smoke-free / fire-safe — widespreadHave policies on smoking.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review, the facility failed to ensure smoking safety was followed on facility grounds per facility policy. This had the potential to affect all 55 residents of the facility. The census was 55. Findings Include: Observation on 04/28/25 at 9:57 A.M. of the facility parking lot with Maintenance Director (MD) #511 revealed cigarette butts disposed of in mulch beds. The mulch bed nearest the facility dumpsters contained 17 cigarette butts. The mulch bed nearest the wooden [NAME]-cochere (a covered porch where vehicles can pick up and drop off people) at the main entrance contained 10 cigarette butts. The trash can under the [NAME]-cochere was observed to have ash marks on the sides of it from cigarettes being extinguished and the inside of the trash can was observed to contain flammable materials. The mulch bed nearest the 300 Hall entrance contained three cigarette butts. Interview on 04/28/25 at 10:08 A.M. with MD #511 confirmed the presence of cigarette butts…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-28 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and review of a bid quote for work from a local construction company, the facility failed to provide a safe and homelike environment. This affected 18 (#4, #6, #8, #10, #15, #17, #18, #19, #22, #23, #25, #36, #37, #38, #39, #42, #46, and #50) of 55 residents reviewed for environment. The facility census was 55. Findings Include: 1. Interview with Resident #19 in the facility's outdoor smoking area on 04/22/25 at 9:50 A.M. revealed the resident did not feel safe in the smoking area and felt it was only a matter of time before the wooden [NAME] structure surrounding the smoking area was going collapse around the residents. Observation of the smoking area on 04/22/25 at 10:00 A.M. revealed the area was covered by a wooden [NAME]. The wood on the structure beams were noted to be visibly rotting to various degrees all throughout the area. The center beam of the [NAME] had an over five and one-half feet long hole in the wood that had been made by a large termite…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-28 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents were transported in the facility in a dignified and respectful manner. This affected one (#37) of one residents reviewed for respect and dignity. The facility census was 55. Findings Include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses that included cocaine abuse, sepsis, and atrial fibrillation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was severely cognitively impaired and required assistance of one staff person for completing his activities of daily living including bathing. Observation of Resident #37 on 04/21/25 at 11:44 A.M. revealed Resident #37 was sitting on a shower chair being pulled by Certified Nurse Aide (CNA) #608 to his room. Resident #37 was observed to be wearing no clothing except for a thin hospital gown with a package of deodorant and an adult incontinence…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-28 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Notice of Medicare Non-Coverage (NOMNC) letters and staff interviews, the facility failed to provide the resident or resident representatives with the name and telephone number of the appeal agency. This affected two (#5 and #8) of three residents reviewed for beneficiary notices. The facility census was 55. Findings include: 1. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. Review of a NOMNC letter revealed skilled services ended on 04/14/25. The letter did not contain the name or the telephone number of the Quality Improvement Organization (QIO) for appeal purposes. 2. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. Review of a NOMNC letter revealed skilled services ended on 03/15/25. The letter did not contain the name or the telephone number of the QIO for appeal purposes. Interview on 04/28/25 at 11:20 A.M. with Chief Clinical Officer (CCO) #509, during review of Resident #5 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-28 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, and staff interview, the facility failed to ensure a resident was properly assessed for use of a restraint. This affected one (#18) of three residents reviewed for restraints. The census was 55. Findings included: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included sepsis, Alzheimer's disease, dementia, diabetes, hypertension, and depression. Review of the plan of care dated 11/29/24 revealed Resident #18 had the potential for pressure ulcer development related to a skin tear to the right fifth digit. Interventions included garden gloves at all times except while sleeping with instructions to remove at night for washing and to check skin integrity dated 04/17/25. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #18 had severely impaired cognition. Review of the progress note dated 04/09/25 at 12:35 P.M. revealed the nurse discussed options with the legal representative…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-28 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure resident Preadmission Screening and Resident Review (PASARR) assessments were updated and accurate. This affected one (#52) of two residents reviewed for PASARR assessments. The facility census was 55. Findings Include: Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses that include dementia, schizophrenia, high cholesterol, and retention of urine. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 was severely cognitive impaired and required extensive assistance of one staff person for completing his activities of daily living. Review of the PASARR assessment dated [DATE] revealed the facility did not indicate the resident had a diagnosis of schizophrenia for the the question on the PASARR assessment, Does the individual have a diagnosis(es) of any of the mental disorders listed below?, with a listing of significant mental health…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-28 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, review of narcotic count sheet, and resident and staff interview, the facility failed to ensure medications were available as ordered to treat pain. This affected one (#19) of five residents reviewed for unnecessary medications. The facility census was 55. Findings included: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, angiodysplasia of the stomach and duodenum with bleeding, urinary tract infections, skin cancer, necrotizing fasciitis, polyneuropathy, mild protein calorie malnutrition, diabetes, chronic kidney, mood disorder, suicidal ideations, chronic obstructive pulmonary disease, chronic pain syndrome, cirrhosis of the liver, hypertension, congestive heart failure, depression, sleep apnea, and anxiety disorder. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #19 had intact cognition and had almost constant pain. Review of the April 2025 physician's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-28 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, pharmacy recommendation review, and staff interview, the facility failed to act upon pharmacist recommendations that were agreed to by the residents physicians as required. This affected two (#51 and #54) of five residents reviewed for unnecessary medications. The facility census was 55. Findings Include: 1. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, anxiety disorder, and depression. There were no other mental health or behavioral related diagnoses present in the medical record. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was severely cognitively impaired, required extensive assistance of one staff person for completing her activities of daily living, and had no verbal, physical, or other behaviors. Review of Resident #51's admission physician's orders from October 2024 revealed an order dated 10/16/24 noting that Resident #51…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-28 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of pharmacy recommendations, staff interview, and policy review, the facility failed to ensure appropriate indications and/or diagnoses were in place for residents receiving antipsychotic medication. This affected one (#51) of five residents reviewed for unnecessary medications. The facility census was 55. Findings Include: Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, anxiety disorder, and depression. There were no other mental health or behavioral related diagnoses present in the medical record. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was severely cognitively impaired, required extensive assistance of one staff person for completing her activities of daily living, and had no verbal, physical, or other behaviors. Review of Resident #51's admission physician's orders from October 2024 revealed an order dated 10/16/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-28 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interview with staff, the facility failed to ensure a resident was given insulin as ordered. This affected one (#19) of five residents reviewed for unnecessary medications. The facility census was 55. Findings included: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, angiodysplasia of the stomach and duodenum with bleeding, urinary tract infections, skin cancer, necrotizing fascitis, polyneuropathy, mild protein calorie malnutrition, diabetes, chronic kidney, mood disorder, suicidal ideations, chronic obstructive pulmonary disease, chronic pain syndrome, cirrhosis of the liver, hypertension, congestive heart failure, depression, sleep apnea, and anxiety disorder. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #19 had intact cognition and received insulin. Review of the April 2025 physician's orders revealed Resident #19 had an order for Novolog Flexpen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · D2025-04-28 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, and interview with the staff, the facility failed to ensure residents were provided thickened liquids as ordered. This affected one (#29) of three residents reviewed for nutrition. The census was 55. Findings included: Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis, hypothyroidism, hypertension, restless legs syndrome, essential tremor, collapsed vertebrae, polyneuropathy, low back pain, spondylosis, repeated falls, slurred speech, disorder of the peripheral nervous system, diabetes, dementia without behaviors, cerebral infarction, major depressive disorder, Alzheimer's disease, and anxiety disorder. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #29 had moderately impaired cognition, required supervision with eating, received a therapeutic diet, and did not have an weight loss. Review of the April 2025 physician's orders revealed Resident #29 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to maintain proper infection control measures during wound care and bed linen changes. This affected two (#29 and #33) of two residents observed for proper infection control measures maintained during care and services. The census was 55. Findings include: 1. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis, hypothyroidism, hypertension, restless legs syndrome, essential tremor, collapsed vertebrae, polyneuropathy, low back pain, spondylosis, repeated falls, slurred speech, disorder of the peripheral nervous system, diabetes, dementia without behaviors, cerebral infarction, major depressive disorder, Alzheimer's disease, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had moderately impaired cognition. Review of the April 2025 physician's orders revealed Resident #29 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-26 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of QSO-24-08-NH and review of facility policy, the facility failed to ensure enhanced barrier precaution (EBP) guidelines were followed for all residents that required EBP. This affected five of ten residents (Resident #1, #23, #50, #51, #57) reviewed for EBP. The facility census was 59. Findings Include: 1. Review of the medical record for Resident #23 revealed and admission date of 12/07/23. Diagnoses included respiratory disorders, tracheostomy, morbid obesity and acute respiratory failure with hypoxia. Review of the Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #23 had intact cognition. Resident #23 was on oxygen, required suctioning, had a tracheostomy and required a mechanical ventilator for respiratory support. Review of the physician orders for April 2024 revealed Resident #23 was on Levofloxacin (antibiotic) 500 milligram (mg) tablet for ten days for pneumonia. There were also orders for tracheostomy care, use of ventilator and suctioning when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-17 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to timely address a resident change in condition. This affected one resident (Resident #65) of three residents reviewed for notification of changes. The facility census was 62. Findings include: Review of Resident #65's closed medical record revealed an admission date of 01/13/23 and diagnoses including anemia, failure to thrive, type two diabetes, hypertension, chronic kidney disease, congestive heart failure, mild cognitive impairment, cardiomegaly, COVID-19, heart disease and hypokalemia. Resident #65 was his own responsible party. Resident #65 discharged to the hospital on [DATE] and did not return to the facility. Review of Resident #65's admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 was moderately cognitively impaired and required minimal assistance to supervision with activities of daily living. Resident #65 was coded as receiving a diuretic six out of seven days in the seven-day look…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-10-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a clean and sanitary kitchen area and ensure appropriate glove usage. This had the potential to affect all 57 of 57 residents receiving meals from kitchen, as the facility identified no residents with nothing by mouth diet orders. Findings include: Observations on 10/17/22 from 11:30 A.M. to 12:15 P.M. of facility kitchen revealed significant dried food debris and dark grease build up on floors, under equipment, and in corners of kitchen. The floor left a sticky substance on shoes throughout kitchen. Observation of juice machine revealed dried juice spray on wall next to the machine. Observed cleaning cloths and food wrappers on ground stuck between prep table holding microwave and wall. Observation of large food preparation table in middle of kitchen revealed storage drawer handles were sticky and had crumbs within drawers, there was dried food splatter and debris on lower shelving of tables and legs, and an open undated container of liquid margarine on lower-level shelf. Observation of oven revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-24 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure Resident #11 and Resident #53's room was uncluttered to maintain a safe environment. This affected two residents (Resident #11 and Resident #53) out of 57 residents reviewed for accommodation of needs. The facility census was 57. Findings include: 1. Resident #53 was admitted on [DATE] with diagnoses including malnutrition, chronic obstructive pulmonary disease, dementia with behaviors, delusional disturbances, iron deficiency anemia, constipation, aortic valve stenosis, congestive heart failure, fracture of the right femur, asthma, unsteadiness, difficulty walking and muscle weakness. Review of Resident #53's Minimum Data Set (MDS) assessment dated [DATE] revealed he needed extensive assistance of two staff members for bed mobility and transfers. Review of Resident #53's fall assessment dated [DATE] revealed he had a moderate risk for falls. Review of Resident #53's plan of care revealed he was at risk for falls related to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and medical record review, the the facility failed to properly treat Resident #21's constipation. This affected one resident (Resident #21) out of one resident reviewed for constipation. Findings include: Review of Resident #21's medical record revealed an admission date of 11/16/20 with diagnoses including acute kidney failure, muscle weakness, morbid obesity, and acquired absence of right leg above the knee. Review of Resident #21's Care Plan dated 07/01/22 revealed the resident was at risk for constipation due to decreased mobility and medications. Interventions included for the facility to follow their bowel protocol for bowel management and record bowel movement patterns each day. Review of Resident #21's October 2022 physicians orders revealed the resident had orders for MiraLax Packet with instructions to give 17 grams by mouth every 24 hours as needed for constipation and Bisacodyl Suppository with instructions to insert one suppository rectally every 24 hours as needed for constipation. Additionally the resident was noted to be on several…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure Resident #24's pressure ulcer treatment was completed as ordered. This affected one resident (Resident #24) out of one resident reviewed for pressure ulcers. Findings include: Review of resident #24's medical record revealed an admission date of 10/18/22 with diagnoses including major depressive disorder, diabetes mellitus, and an unstageable pressure ulcer to right great toe. Review of Resident #24's Care Plan, dated 05/23/22, revealed the resident was at risk for impaired skin integrity due to anemia, vitamin D deficiency, diabetes, and osteomyelitis. Intervention included to complete medications and treatments as ordered. Review of Resident #24's October 2022 physicians orders revealed an order to clean the resident's right great toe stump with wound cleaner, apply skin prep, cover with an abdominal pad, and wrap with gauze every day shift and as needed. Observation on 10/18/22 at 11:00 A.M. revealed Assistant Director of Nursing (ADON) #242 complete the pressure dressing change for Resident #24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-24 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation record review and interview the facility failed to maintain Resident #30's right hand splint to prevent contracture. This affected one out of four residents reviewed for limited range of motion. The facility census was 57. Findings include: Resident #30 was admitted on [DATE] with diagnoses including stoke, kidney stone, high blood pressure, aortic aneurysm, congestive heart failure and hyperlipidemia. A review of Resident #30's occupational therapy discharge note indicated he received occupational therapy services from 08/10/22 to 09/22/22. The occupational therapy recommended a restorative program for a restorative splint and brace program. Resident #30 was to wear a right hand splint to decrease further contracture as tolerated. Resident #30's physician order dated 09/14/21 indicated to apply a right hand splint daily as tolerated. There was no documentation in Resident #30's clinical record of Resident #30 refusing to wear the splint or removing the splint after the staff applied the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure Resident #37 and #43 had nutritional interventions implemented timely. This affected two residents (Resident #37 and Resident #43) out of four residents reviewed for nutrition. Findings include: 1. Review of Resident #43's medical record revealed an admission date of 10/16/19 with diagnoses including dementia, hypertension, anemia and GERD. Review of Resident #43's Minimum Data Set 3.0 assessment, dated 09/17/22, revealed the resident had intact cognition and required supervision and set help for eating. Review of Resident #43's weight record revealed a 04/01/22 weight of 138.6 pounds and a 08/27/22 weight of 131.4 pounds. Review of Resident #43's 08/11/22 nutrition note by Dietitian #272 stated a weight loss notification was triggered for the resident. The resident's body mass index revealed underweight status at 17.9. The resident exhibited clinical signs of malnutrition. Added interventions included eight ounces…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-24 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy and procedure review, the facility failed to maintain a medication error rate of less than five (5) percent (%). The medication error rate was calculated to be 6.9% and included two medication errors of 29 medication administration opportunities. This affected two residents (#11 and #26) of six residents observed during medication administration. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 05/11/21 with diagnoses including anxiety disorder, hypertension, major depressive disorder, and epilepsy. Review of the October 2022 physician's orders revealed Resident #11 had an order to receive Hydralazine HCL 25 milligrams (mg) by mouth twice daily for hypertension. Observation on 10/19/22 at 8:25 A.M. revealed Licensed Practical Nurse (LPN) #233 administered Resident #11 Hydralazine HCL 50 mg. Interview on 10/19/22 at 8:38 A.M. with LPN #233 confirmed she administered Resident #11 Hydralazine HCL 50 mg when he was ordered to receive Hydralazine 25 mg. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2019-11-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview the facility failed to ensure the kitchen area was maintained in a clean and sanitary manner and that all food was labeled, dated and stored properly. This had the potential to affect all residents. The facility census was 50. Findings include: During the initial kitchen tour conducted on 11/24/19 between 8:00 A.M. and 8:19 A.M. the following was observed and verified with [NAME] #22. 1. A half of a ham in the cooler was covered in Saran wrap with no date or label. 2. Four open packages of turkey deli meat were in the cooler with no date or label. 3. An open package of mustard was in the dry storage area with no date. 4. A package of Brussel sprouts in the freezer was open, undated and exposed to air. 5. The air vents located above the food prep area and the steam table used to store cooked food prior to meal service were rusted and had noticeable instances of dust and other dirt that was easily flaked off with the touch of a finger. Review of the undated policy titled Food storage revealed food will be stored under sanitary conditions.
- Potential for harm · Fcited before2019-11-26 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and record review, the facility failed to ensure infection control practices were followed for isolation precautions for one resident (Resident #31) with clostridium difficile (C-diff). This had the potential to affect all 50 residents who resided in the facility. Findings include: Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, major depressive disorder, diabetes mellitus, clostridium difficile colitis and speech and language development delay due to hearing loss. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/10/19 revealed the resident had the absence of useful hearing and was cognitively intact. The resident required extensive assistance of two staff for most activities of daily living. Review of Resident #31's care plan dated 11/19/19 revealed contact isolation. Observation on 11/24/19 at 9:15 A.M. revealed Housekeeper #63 was wearing the same pair of gloves coming out of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-11-26 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview the facility failed to maintain a clean and sanitary environment for Residents #5, #6, #10, #11, #12, #13, #14, #17, #18, #20, #28, #35, #38, #40, #148, #248. This affected 16 of 50 residents. Findings include: An environmental tour was conducted with Maintenance Director (MD) #35 on 11/25/19 between 6:58 A.M. and 7:22 A.M. The following was observed and verified by MD #35 during the environmental tour. 1. The rooms belonging to Residents #5, #10, #12, #14, #17, #28 and #148 contained privacy curtains that were stained to various degrees by unknown substances. 2. The room belonging to Resident #35 had a crack in the tile floor. 3. The window seal and ledge was cracked in half in Resident #11's room. 4. The sheets on Resident #13's bed were noticeable stained by an unknown substance. 5. The room belonging to Residents #6 and #40 had numerous broken vertical blinds. 6. The toilet in the room belonging to Residents #18 and #20 was stained dark brown in color. 7. The toilet seat in the room belonging to Resident #38 had dried fecal matter on it.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-26 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure personal resident information was communicated in a way to protect the confidentiality of the information and the dignity of the resident. This affected one of 50 facility residents, Resident #31. Facility census was 50. Findings include: Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, major depressive disorder, diabetes mellitus, clostridium difficile colitis and speech and language development delay due to hearing loss. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/10/19 revealed the resident had the absence of useful hearing and was cognitively intact. The resident required extensive assistance of two staff for bed most activities of daily living. Observation on 11/24/19 at 11:55 P.M. revealed a sign posted on the hallway wall, outside Resident 31's room indicating: Resident is deaf, please get resident's attention as soon as you enter the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-11-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to ensure as needed (PRN) medication orders for psychotropic drugs were limited to 14 days and failed to timely follow pharmacy recommendations. This affected one Resident (Resident #27) of five residents reviewed for unnecessary medications. Findings include: Review of Resident's #27 medical record revealed an admit date of 05/17/17 with diagnoses of major depression disorder, psychosis and dementia. The Minimum Data Set (MDS) 3.0 assessment revealed the resident had moderate depression, trouble falling asleep and concentrating. Resident #27 exhibited physical and verbal behaviors directed toward others. Review of the signed physician orders for May 2019 revealed Resident #27 had a PRN order dated 05/23/29 for Ativan (antianxiety medication) 0.5 milligram (mg) every six hours as needed. Review of the Pharmacist's Medication Regimen Review dated 06/21/19 revealed the order for Ativan 0.5 mg every six hours as need was due for a re-evaluation. Review of the pharmacy note to the attending physician dated 06/21/19 revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-04-28 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation of the posted survey results, review of previous survey history, and staff interview, the facility failed to ensure posted survey results were updated with the most recent survey results. This had the potential to affected all 55 residents. The facility census was 55. Findings include: Observation of the facility survey results binder on 04/28/25 at a random time found the last survey included was dated 06/10/22. Review of facility's survey history revealed, between 06/10/22 and 04/28/25, there were eleven complaint surveys, an annual survey on 10/24/22, and 15 Focused Infection Control surveys completed. Interview on 04/28/25 at 10:56 A.M. with the Administrator confirmed there were no survey results in the facility binder since 06/10/22.
- No harm found · C2019-11-26 · tag F0576 — widespreadEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — the official record, unedited, may be distressing
Based on resident and staff interview the facility failed to ensure mail was delivered to residents on Saturdays. This affected five residents (Residents #11, #34, #36, #45 and #249) and had the potential to affect all 50 residents residing in the facility. Findings include: During the resident council portion of the annual survey conducted on 11/25/19 between 1:00 P.M. and 1:30 P.M. with Residents #11, #34, #36, #45 and #249 multiple concerns were expressed that residents were not receiving mail on Saturdays. Interview with Activities Director #49 on 09/12/18 at 1:45 P.M. revealed she was in charge of passing out resident mail on they days she worked. Activities Director #49 verified resident mail was not being delivered on Saturdays and that often their was a stack of mail to be passed out on Monday mornings when she came to work.
- No harm found · C2019-11-26 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview the facility failed to ensure posted nursing staff information was updated timely. This had the potential to affect all residents. The facility census was 50. Findings include: Observation of the posted nursing staff information on 11/25/19 at 10:15 A.M. revealed the posted nursing staff information was from 11/24/19. Interview on 11/25/19 at 10:17 A.M. with Assistant Director of Nursing #43 verified the posted nursing staff information was not up to date.
- No harm found · C2019-11-26 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview the facility failed to ensure the garbage disposal area was maintained in a clean and sanitary condition. This had the potential to affect all 50 residents residing in the facility. Findings include: Observation of the facility garbage disposal area on 11/24/19 at 10:00 A.M. revealed two dumpsters positioned side by side, both overflowing with garbage bags and with numerous bags of garbage laying on the ground surrounding the dumpsters. Interview with Dietary [NAME] #22 and the Administrator verified the above observations at the time of discovery.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2025-07-28 for 39 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PHOENIX HEALTH SERVICES LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2019 |
| SCHONFELD, LOUIS | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 01/01/2019 |
| SCHONFELD, BERNARD | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2019 |
CMS files one row per role, so the 6 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $300K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365707. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.