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The Laurels Of Chagrin Falls

150 Cleveland Street, Chagrin Falls, OH 44022 · For profit - Limited Liability company · 82 certified beds · (440) 247-4200 Medicare & Medicaid certified

Call the home — (440) 247-4200 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (2/5)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
306 · (440) 338-3366 · Call to confirm hours
Pharmacy
34 Shopping Plz · (800) 746-7287 · Call to confirm hours
Grocery
20 Shopping Plz
Park
34 E Orange St · Typically dawn to dusk
Place of worship
76 Bell St · (440) 247-6490

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 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 1 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 1 to 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.8%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight9.0%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.8%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.9%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury7.5%3.2%3.3%worse
Long-stay residents whose ability to walk worsened4.9%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication22.6%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine91.7%94.5%95.3%typical
Long-stay residents with pressure ulcers5.5%3.4%4.7%worse
Long-stay residents with worsening bladder/bowel control29.6%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.3%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication2.5%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine51.4%75.6%79.4%worse
Short-stay residents rehospitalized after admission35.6%24.9%22.6%worse
Short-stay residents with an outpatient ER visit8.3%12.9%12.0%better

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.

0.46U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.27hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot 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 dischargenot 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 stay5.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened20.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot 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 SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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

1.08
RN hours/ resident / day
0.71
LPN hours/ resident / day
1.92
Aide hours/ resident / day
3.71
Total nurse hours/ resident / day
0.62
RN hoursweekends
50.0%
Total nursing turnover
41.7%
RN turnover

How full it usually is: this home is certified for 82 beds and averages 37.4 residents a day — about 46% occupied, or roughly 45 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 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.08 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 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 3.14 hrs/resident/day on weekends vs 3.95 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.27 to 0.62 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%. 1 administrator has left in the past year.

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

5
deficiencies at the latest standard inspection (2025-02-06)
13
at the previous standard inspection (2022-12-12)

Deficiencies are fewer than at the previous inspection — improving. 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.

ABCDEFGHIJKL

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.

26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · G2022-12-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure residents received adequate, necessary and timely care and treatment to meet their total care needs. The facility failed to ensure antibiotics and x-rays were completed as ordered for Resident #16, failed to ensure monthly weights were completed for Resident #1, and failed to ensure physician orders were in place for blood glucose monitoring of Resident #84. Actual Harm occurred on 12/08/22 when Resident #16, who was cognitively impaired and required staff assistance for activities of daily living was admitted to the hospital with a diagnosis of sepsis (blood infection) related to a wound to the left heel. Physician's orders for the antibiotic, Doxycycline and imaging to rule out osteomyelitis were not completed as ordered contributing to the hospitalization. This affected one resident (#16) of one resident reviewed for wounds and two residents (#1 and #84) of 14 sampled residents. The facility identified one resident as having…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2022-12-12 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview the facility failed to ensure antibiotics were ordered and administered to Resident #16 in a timely manner to treat suspected osteomyelitis (bone infection). Actual Harm occurred on 12/08/22 when Resident #16 was admitted to the hospital with a diagnosis of sepsis (blood infection) related to a wound to the left heel. Physician order for the antibiotic, doxycycline was not obtained as recommended to treat suspected osteomyelitis contributing to the hospitalization. This affected one resident (#16) of one resident reviewed for wounds. The facility identified one resident as having wounds, Resident #16. The facility census was 34. Findings include: 1. Review of Resident #16's medical records revealed an admission date of 09/16/22 with diagnoses including non pressure chronic ulcer of right foot, peripheral vascular disease (PVD) and diabetes. Resident #16 was admitted with two unstageable pressure ulcers (areas were not identified). Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/25/22 revealed Resident #16 had impaired…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-09 · tag F0895 — widespread
    Have a Compliance and Ethics 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 personnel record review, review of the facility ' s Background Check log, review of the [NAME] Municipal Court docket, staff schedule review, staff member handbook review, review of the Ohio Administrative Code (OAC), and interview, the facility failed to ensure direct care staff, Certified Nurse Aide (CNA) #46, did not continue to provide direct care to residents after she was convicted of a disqualifying offense according to State law. This had the potential to affect all residents residing in the facility. The census was 34.Findings include:Review of Certified Nurse Aide (CNA) #46's personnel record revealed a hire date of 06/04/25. Review of the Ohio Department of Health Nurse Aide Registry (NAR) (within CNA #46's personnel record) dated 06/03/25 revealed CNA #46 was eligible to work and in good standing. Review of the Ohio Attorney General Criminal History Record Check dated 06/13/25 (within CNA #46's personnel record) revealed CNA #46 had a criminal history and was arrested and charged with…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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, resident interview, and staff interview, the facility failed to ensure sufficient bathing was provided to all dependent residents. This affected two (Residents #1 and #20) of three residents reviewed for activities of daily living (ADL). The census was 45. Findings Include: 1. Resident #1 was admitted to the facility on [DATE]. His diagnoses were infection and inflammatory reaction due to indwelling urethral catheter, sepsis due to MRSA, COPD, muscle wasting and atrophy, dysphagia, type II diabetes, urinary tract infection, obstructive and reflux uropathy, unspecified severe protein calorie malnutrition, congestive heart failure, pleural effusion, hypertensive heart and chronic kidney disease, acute kidney failure, atrial fibrillation, anemia, aortic stenosis, and hyperlipidemia. Review of his Minimum Data Set (MDS) assessment, dated 04/17/25, revealed he had mild cognitive impairment and was dependent on staff for bathing/showering. Review of Resident #1 current shower schedule…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 interview the facility failed to ensure care conferences were completed quarterly for Residents #13 and #14. This affected two of three residents whose records were reviewed for care conferences. The facility census was 42. Findings include: 1. Record review revealed Resident #14 was admitted [DATE] with diagnoses of chronic obstructive pulmonary disease, malignant neoplasm of prostate, paranoid schizophrenia, and unspecified dementia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated a moderate cognitive impairment. Review of the functional abilities section of the MDS assessment revealed no impairment however Resident #14 utilized a wheelchair for locomotion. Review of the completed care conference documentation revealed Resident #14 had care conferences 03/26/24 and 08/26/24. There was no evidence found in the medical record that indicated a care conference…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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's pressure ulcer wound care was completed as ordered. This affected one (Resident #11) of one resident reviewed for pressure ulcer wounds. Findings include: Review of Resident #11's medical record revealed the resident was admitted [DATE] with diagnoses including senile degeneration of the brain, essential hypertension and major depressive disorder. Review of Resident #11's care plans revealed an intervention dated 10/29/24 for treatments to skin impairments as ordered. Review of Resident #11's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #11's physician orders revealed an order dated 01/10/25 to cleanse the left heel wound with normal saline, pat dry, apply betadine to the wound and cover with an abdominal (ABD) pad and Kerlix every night shift for wound care. Review of Resident #11's physician orders revealed an order…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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, record review and interview, the facility failed to ensure Resident #3's nutritional supplement was implemented as planned. This affected one (Resident #3) of two residents reviewed for nutrition. Findings include: Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease, hypertensive heart disease with heart failure and mild cognitive impairment. Review of Resident #3's physician orders revealed an order dated 10/03/24 for a regular diet, regular texture, thin consistency. Review of Resident #3's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited cognitive impairment. Review of Resident #3's dietary progress note dated 12/31/24 at 11:48 A.M. revealed the resident was slightly underweight and the regular diet remained tolerated. The resident had between meal supplements in place for nutrition support and snacks were noted in the resident's room. Review of Resident #3's lunch…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-06 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 and interview, the facility failed to ensure Resident #36's expired insulin was discarded as appropriate. This affected one (Resident #36) of five residents observed for medication administration. Findings include: Observation on [DATE] at 12:15 P.M. with Licensed Practical Nurse (LPN) #822 revealed LPN #822 completed blood glucose testing for Resident #36 with a result of 175. LPN #822 then administered three units of Humalog fast acting insulin into the resident's right arm using a Humalog Kwikpen. The date first used written on the Kwikpen in marker was [DATE]. Interview on [DATE] at 12:20 P.M. with LPN #822 confirmed Resident #36's Humalog Kwikpen was expired and should have been discarded after 28 days after first being used. The Humalog Kwikpen expired [DATE]. Review of the Insulin Lispro (Humalog) KwikPen Instructions for Use form revised [DATE] revealed an in-use pen should be stored at room temperature up to 86 degrees Fahrenheit and away from heat and light. The pen should be…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-06 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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, record review and interview, the facility failed to ensure the blood glucose testing (BGT) machine/glucometer was appropriately cleaned and disinfected to prevent the potential cross-contamination of blood borne pathogens affecting one resident (Resident #36) with the potential to affect an additional resident (Resident #24) whose medications were stored in the Nurse Station 2 medication administration cart. The facility also failed to ensure appropriate hand hygiene, appropriate glove use, and appropriate cleaning technique were implemented during Resident #29's catheter care affecting one resident (Resident #29) of two residents reviewed for catheter care. Findings include: 1. Review of Resident #24's medical record revealed the resident was admitted on [DATE] with diagnoses including hemiplegia, type two diabetes and chronic obstructive pulmonary disease. Review of Resident #24's physician orders revealed an order dated 10/30/24 for sliding scale insulin; inject Humalog as per sliding…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-29 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and menu spreadsheet review, the facility failed to follow the menu as written. This affected two residents (#16 and #34) of two residents receiving a puree diet. Facility census was 36. Findings include: Review of the menu spreadsheet for week two, Thursday corresponding to 08/29/24 revealed portions of the menu were to be served as followed for those receiving pureed meals: five ounces pureed sloppy joes, four ounces pureed tater tots, four ounces pureed lima beans, six ounces pureed soup of the day and two ounces pureed cookie (no nuts). Review of the facility resident diet list revealed Resident #16 and #34 received pureed diets. Observation of lunch tray service on 08/29/24 at 12:24 P.M. revealed the trays for the two residents on a pureed diet (Resident #16 and Resident #34) were at the end of the tray line. Certified Dietary Manager (CDM) #52 was plating meals during service and brought two divided plates over to the serving area. A blue #16-scoop (two ounces) was placed into the pan with the pureed sloppy joe meat, a blue #16-scoop was placed…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-12-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 facility policy review, the facility failed to maintain a clean, sanitary kitchen area, ensure foods were stored in a clean and sanitary manner to prevent contamination and food borne illness, and ensure expired products were discarded. This affected all 34 residents residing at the facility receiving meals. Findings included: 1. Observation on 12/04/22 at 8:10 A.M. during tour of the kitchen with Dietary Manager #410 revealed heavily soiled floors throughout the kitchen. The cold air return vent on the opposite wall of the dish machine revealed a heavily soiled vent on the wall with thickened black dust on the grates with peeling paint. Mold that was black in color was visible on the ceiling above the dish machine, and the exhaust pipe from the dish machine to the outside wall had mold and peeling paint over the area where clean dishes were discharged from the dish machine. A light switch with metal tubing covering the electrical wires going from the wall switch towards the ceiling had peeling paint above the clean dish lane where clean trays of…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-12 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    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 residents received scheduled and appropriate activities on the weekend. This affected Residents #7, #21, #22 and #84 and had the potential to affect all 34 residents in the facility. Findings include: Record review of the facility activity calendar revealed on Sunday 12/04/22 the following activities were scheduled: Trivia and coffee at 1:00 P.M., floats and tunes at 2:00 P.M., and word puzzles at 3:00 P.M. This exact schedule was also in place for Sunday 12/11/22 and Sunday 12/18/22. Interview with Resident #22 on 12/04/22 at 9:22 A.M. revealed the facility occasionally had activities on Saturday, otherwise there were no activities over the weekend. Observation of the facility common and activity rooms on 12/04/22 at 1:27 P.M. revealed no evidence of any organized activities in progress. Two large whiteboards in common rooms had the day's activity schedule prominently posted. Interview with State-Tested Nursing Aide #443 on 12/04/22 at 1:37 P.M. revealed she knew of no activity workers currently in…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · E2022-12-12 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure 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 interview and record review, the facility failed to ensure resident physicians signed and acted on pharmacy recommendations. This affected four of five (Residents, #1, #7, #12 and #15) residents reviewed for unnecessary medications. The total census was 34. Findings include: 1. Record review of Resident #12 revealed she was admitted [DATE] and had diagnoses including hyperlipidemia, dementia with behavior disturbances, and major depressive disorder. Her medications included Atorvastatin (an anti-hyperlipidemia medication) and 2 milligrams of Aripiprazole (an antipsychotic) daily. Review of resident #12's pharmacy record reviews revealed a consultation report dated 03/08/22 which recommended a lipid panel be drawn on the next convenient lab day and yearly thereafter. The report was signed as accepted on 06/08/22, however her records revealed no evidence the lab was drawn although she had seven blood draws since the time of the order. Another consultation report dated 07/22/22 noted she had received 2…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-12 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    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 a medication error rate of less than five percent. The medication error rate was 10.71 percent. Three errors occurred in 28 opportunities for error. This affected two residents (#22 and #36) of five residents observed for medication administration. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 12/04/21 with diagnoses including type II diabetes, hypertension, and kidney transplant. Review of the care plan dated 10/27/22 revealed Resident #22 was at risk for fluctuation of blood sugar levels related to type II diabetes and end stage renal disease. Interventions included to administer medications as ordered and to observe for signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had intact cognition and received insulin by injection. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-12 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure Resident #184's baseline care plan addressed the resident's chronic pain. This affected one resident (#184) of three residents reviewed for baseline care plans. The facility census was 32. Findings include: Review of Resident #184's medical records revealed an admission date of 12/02/22, with no listed diagnosis. Review of current physician orders for December 2022 revealed #184 was ordered Percocet (narcotic pain medication) 10-325 milligrams (mg) every eight hours for chronic pain. Review of Resident #184's baseline care plan dated 12/02/22 revealed the care plan did not address Resident #184's chronic pain. Interview on 12/04/22 at 2:20 P.M. with Resident #184's husband revealed Resident #184 was taking narcotic pain medication prior to her admission for chronic pain in her arm and shoulder and was unable to state the exact dosage, however he stated it was a lot. Observation on 12/05/22 at 8:48 A.M. revealed Resident #184 was lying in bed and was yelling out for a nurse. Upon entering Resident #184's room,…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 interview and record review the facility failed to ensure care plans accurately reflected the needs and care to be provided. This affected two residents (#8 and #1) of five reviewed for care planning. The facility census was 34. Findings include: 1. Review of Resident #8's medical records revealed an admission date of 12/04/21. Diagnoses included muscle spasms and diabetes. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had intact cognition, required extensive assistance with bed mobility, toileting and personal hygiene and total assistance with transfers. Review of Resident #8's care plan dated 10/27/22 revealed no care plan in place for the use of a hand splint. Review of the current physician orders for December 2022 revealed no orders related to the use of hand splint. Observation on 12/04/22 at 11:18 A.M. revealed Resident #8 had a splint to his left hand and the left hand appeared to be contracted. Interview with Resident #8 at time of observation revealed he wore…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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 ensure to care planning and a physician's order were in place for use of a hand splint for Resident #8. This affected one of 14 sampled residents. Facility census was 34. Findings include: Review of Resident #8's medical revealed an admission date of 12/04/21 with a diagnosis including muscle spasms. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had intact cognition, and required extensive assistance with bed mobility, transfers, toileting and personal hygiene. Observation on 12/04/22 at 11:18 A.M. revealed Resident #8 had a splint to his left hand and the hand appeared to be contracted. Interview with Resident #8 at time of observation revealed he wore the splint most of the time and stated the staff did not always take it off prior to bed. Observation on 12/05/22 at 6:55 A.M. revealed Resident #8's hand splint was on the resident's bedside table. Interview on 12/05/22 at 6:58 A.M. with State Tested…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-12 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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 interview and record review, the facility failed to ensure gradual dose reductions (GDRs) were attempted or considered for psychotropic medications. This affected one of five (Resident #12) residents reviewed for unnecessary medications. The total census was 34. Findings include: Record review of Resident #12 revealed she was admitted [DATE] and had diagnoses including dementia with behavioral disturbances and major depressive disorder. Her medications included 2 milligrams of Aripiprazole (an antipsychotic) daily, ordered 09/02/21. Record review of a pharmacy consultation report dated 07/22/22 noted she had received 2 milligrams Aripiprazole daily since her admission and recommended a dose reduction be attempted. The report had no signature indicating it was read by or communicated to the physician. Review of her other records revealed no evidence any dose reduction was assessed or attempted within the past year. Interview with the Director of Nursing on 12/06/22 at 10:36 A.M. confirmed the above…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-12 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 interview and record review, the facility failed to draw blood labs according to orders. This affected two of five residents (Resident #12 and #4) reviewed for unnecessary medications. The total census was 34. Findings include: 1. Record review of Resident #4 revealed she was admitted [DATE] and had diagnoses including paranoid schizophrenia, iron deficiency anemia, type 2 diabetes, hyperlipidemia, vitamin B-12 deficiency, and vitamin D deficiency. Her medications included Vitamin B-12, Vitamin D, and iron supplements, Atorvastatin (an anti-hyperlipidemia medication), and insulin injections. She had active orders for a yearly lipid panel (blood draw) dated 07/24/19, a HgB A1c (diabetic lab), CBC (complete blood count), and LFT (liver function test) blood draw every six months dated 06/14/21, and a CBC, CMP (complete metabolic panel), HgB A1C, lipid panel, Vitamin B-12, and Vitamin D lab draw ordered 08/04/22. Record review of Resident #4's laboratory documentation for the past year revealed blood draw…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-12 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to ensure baths or showers were documented appropriately. This affected one of four residents reviewed for choices and activities of daily living (Resident #84). The total census was 34. Findings include: Interview with a family member of Resident #84 on 12/04/22 at 12:10 P.M. revealed they felt the resident was not bathed regularly. Observation of Resident #84 at this time revealed he was not interviewable; Resident #84 did not appear unkempt or unclean, and no odor was noted. Record review of Resident #84 revealed he was admitted to the facility 11/19/22 and had diagnoses including cognitive communication deficit, hyperkalemia and type 2 diabetes. Review of Resident #84's nurse aide tasks log revealed the resident was supposed to have a bath or shower every Wednesday and Saturday. Review the bathing sign-off section revealed no documentation Resident #84 received any bathing while at the facility. Interview with the Director of Nursing on 12/07/22 at 4:16 P.M. confirmed the above findings

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2020-01-04 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 properly store, prepare and maintain food in a clean and sanitary manner in the main kitchen and one nursing unit refrigerator. This had the potential to affect all residents except three residents (Residents #14, #16, and #30) who received nothing by mouth. The facility census was 41. Findings include: 1. Tour of the main kitchen on 01/02/20 from 8:38 A.M. to 9:07 A.M. with Dietary Staff (DS) #339 revealed the electric stove had dried grease stains on the surface, backsplash, and down the front of the stove. The fryer located between the stove and the steamer, had various grease stains and food debris. The table that held the fryer sat on a moderate amount of grease spillage and food debris. The side of the steamer next to the fryer had various grease splatter that appeared from the fryer. The steam table shelf underneath had various dried spills and what appeared to be dried grease stains along the front of the steam table underneath the lip of the steam table top surface. The floor next to the stove had a…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2020-01-04 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review the facility failed to complete a risk assessment or implement infection control measures for Legionella. This had the potential to affect all 41 residents in the facility. Findings include: Review of the facility's Legionellosis/Legionnaires Disease/Legionella and Other Water-Borne Pathogens Prevention Policy, dated 09/17, revealed the facility had a generic policy for Legionella. The facility had not completed a Legionella or water-borne pathogens risk assessment and they had no monitoring or control measures in place for Legionella prevention. Interview with the Administrator on 01/04/20 at 2:50 P.M. verified a Legionella risk assessment had not been completed and they had no monitoring or control measures in place for Legionella prevention.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2020-01-04 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 serve the correct portion sizes to meet the needs of residents receiving pureed diets. This affected four (Residents #2, #25, #27, and #36) of four residents who received pureed diets. Findings include: Review of the menu for the dinner meal on 01/03/20 revealed beef vegetable stew, biscuit, and tossed salad with dressing was being served. Review of the diet spreadsheet for 01/03/20 revealed the pureed diet was to receive two #10 scoops for the beef vegetable stew (which would equal 6 ounces) and one #10 scoop of pureed vegetable of the day (which would equal 3 ounces). Interview on 01/03/20 at 4:36 P.M. with Dietary Staff (DS) #338 after observing tray line food temperatures revealed she had already plated and placed the pureed food in the cooler since there were only four residents that received pureed diet at dinner. DS #338 stated she would reheat them and take a temperature when they were ready to be served. DS #338 stated she used the gray handled scoop for the pureed beef stew and the green handled…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-04 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 provide adequate activities for Resident #14. This affected one resident (#14) of one reviewed for activities. Findings include: Review of Resident #14's medical record revealed an initial admission date of 08/03/11. Diagnoses included vascular dementia without behavioral disturbance, hemiplegia and hemiparesis (weakness/paralysis on one side of the body) following a stroke affecting the left non-dominant side, and contractures (limited range of motion due to shortened/hardening of tendons) of joints of the right shoulder, elbow, and wrist. The annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #14 had impaired cognition, required extensive assistance of two staff for bed mobility and toilet use, and was totally dependent on two staff for transfers. Review of the care plan initiated on 08/21/19 revealed Resident #14 had a potential for impaired social interaction or social isolation related to impaired cognition due to vascular dementia. Interventions included staff to provide Resident #14 one on…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 fall prevention interventions were consistently implemented as planned for Residents #19 and #47 and the facility failed to ensure smoking assessments, including level of staff supervision were completed for Resident #18. This affected two of four residents reviewed for falls and one of one resident reviewed for smoking. The facility census was 41. Findings include: 1. Medical record review for Resident #19 revealed an admit date of 11/09/18 with diagnoses that included history of falling, Alzheimer's disease, diabetes and heart disease. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had impaired cognition and required extensive assistance from staff for mobility and transfers. Resident #19 had a history of falls and was frequently incontinent of bowel and bladder. Resident #19's care plan initiated on 05/31/19 indicated he/she was at risk for falls due to impaired cognition and muscle…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2022-12-12 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 medications were properly stored. This had the potential to affect all 34 residents residing in the facility. Findings include: 1. Observation of a medication cart on 12/05/22 at 10:37 A.M. with Licensed Practical Nurse (LPN) #445 revealed the medication cart contained numerous loose unidentifiable pills in various compartments of the medication cart. LPN #445 stated she was agency staff and this was her first day at the facility and she did not check the cart for loose pills. 2. Observation of a medication cart on 12/05/22 at 10:40 A.M. with Registered Nurse (RN) #441 revealed numerous loose pills in several areas of the cart as well as three medication cards that contained medications behind a drawer on the bottom of the cart that had made it difficult to completely close the bottom drawer. RN #441 stated she worked for agency and it was her first day at the facility and she was unaware of the loose pills and medication cards that were making it difficult to close the bottom drawer. Interview on…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CIENA HEALTHCARE/LAUREL HEALTH CARE — 81 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.8+0.2 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 3 of 53.2-0.2 vs chain
Quality measures 2 of 54.0-2.0 vs chain
The other 80 homes this chain runs (chain average 2.8★, per CMS)
1 of 5Aria Nursing and RehabilitationLansing, MI 1 of 5Autumnwood of McBainMcBain, MI 1 of 5Christian Park Health Care CenterEscanaba, MI 1 of 5Courtney ManorBad Axe, MI 1 of 5Ely ManorAllegan, MI 1 of 5Kith HavenFlint, MI 1 of 5Laurels Of Norworth TheWorthington, OH 1 of 5Laurels Of West Carrollton TheWest Carrollton, OH 1 of 5Laurels Of West Columbus, TheColumbus, OH 1 of 5Notting Hill of West BloomfieldWest Bloomfield, MI 1 of 5Regency at FremontFremont, MI 1 of 5Regency at JacksonJackson, MI 1 of 5Regency at TroyTroy, MI 1 of 5Regency at WaterfordWaterford, MI 1 of 5Regency at Whitmore LakeWhitmore Lake, MI 1 of 5Royalton Manor, LLCSt Joseph, MI 1 of 5The Laurels Of HeathHeath, OH 1 of 5The Laurels Of Walden ParkColumbus, OH 1 of 5The Laurels of GalesburgGalesburg, MI 1 of 5The Laurels of HudsonvilleHudsonville, MI 1 of 5The Manor of NoviNovi, MI 2 of 5Laurels Of Athens, TheAthens, OH 2 of 5Laurels Of Mt Vernon TheMount Vernon, OH 2 of 5Laurels Of Steubenville TheSteubenville, OH 2 of 5Regency At Bluffs ParkAnn Arbor, MI 2 of 5Regency at CheneDetroit, MI 2 of 5The Laurels Of GahannaColumbus, OH 2 of 5The Laurels Of KetteringKettering, OH 2 of 5The Laurels Of University ParkRichmond, VA 2 of 5The Laurels Of Willow CreekMidlothian, VA 2 of 5The Laurels of BedfordBattle Creek, MI 2 of 5The Laurels of ChathamPittsboro, NC 2 of 5The Laurels of ColdwaterColdwater, MI 2 of 5The Laurels of Forest GlennGarner, NC 2 of 5The Manor of Farmington HillsFarmington Hills, MI 2 of 5Willowbrook ManorFlint, MI 3 of 5Autumnwood of DeckervilleDeckerville, MI 3 of 5Boulevard Temple Care Center, LLCDetroit, MI 3 of 5Brittany ManorMidland, MI 3 of 5Hamilton Respiratory and Nursing CenterHamilton, OH

Showing 40 of 80; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
KHAN, ANISIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2017
QAZI, MOHAMMADIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 09/01/2017
LAUREL HEALTH CARE COMPANYOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/31/2025
KRISHNAN, RAVIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
PALYAK, LINDSEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/10/2025
STOBB, DAVIDIndividualADP OF THE SNFsince 09/01/2017

CMS files one row per role, so the 12 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$3.5M
Net patient revenuemost recent cost report
-62.9%
Operating marginrevenue minus expenses
$179K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 25%Medicare 3%Other / private 72%

This home reported $179K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$400per resident / day
operating cost
$12,167per month
≈ monthly operating cost
$246per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Ohio
$9,186/mo
Nursing home (semi-private)
$10,389/mo
Nursing home (private)
$6,103/mo
Assisted living

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 366274. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-06, 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.

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