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Timberland Ridge Nursing & Rehabilitation

3558 Ridgewood Road, Fairlawn, OH 44333 · For profit - Corporation · 75 certified beds · (243) 466-8689 Medicare & Medicaid certified

Call the home — (243) 466-8689 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Dec 20231 actual-harm citation1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2023
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (58%) runs well above the national median (45%)

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 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS
Urgent care / clinic
3562 Ridge Park Dr · (330) 664-0766 · Call to confirm hours
Pharmacy
1410 S Cleveland Massillon Rd · (330) 666-4101 · Call to confirm hours
Grocery
1238 S Cleveland Massillon Rd · (330) 666-4334 · Call to confirm hours
Park
3232 Copley Rd · (330) 666-1853 · Typically dawn to dusk
Place of worship

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 5 of 5
Long-stay residentspeople who live here 5 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 fell from 4 to 1 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 rating1★
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 increased5.3%5.3%15.4%typical for the 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 infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms47.4%30.1%6.5%worse 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 injury3.2%3.2%3.3%typical
Long-stay residents whose ability to walk worsened6.9%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication19.6%25.5%18.9%typical
Long-stay residents given the seasonal flu vaccine90.6%94.5%95.3%typical
Long-stay residents with pressure ulcers2.5%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control18.0%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table16.1%8.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.9%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine49.3%75.6%79.4%worse

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.

45.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 57 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.3%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
0.30U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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 SNF45.3%CMS range 32.0–57.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 7.6–15.610.7%Oct 2022–Sep 2024no 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 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 identified94.4%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 setting90.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 stay0.0%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 worsened2.8%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 hospitalization7.0%CMS range 3.6–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.181.02Oct 2022–Sep 2024CMS 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

0.61
RN hours/ resident / day
1.06
LPN hours/ resident / day
2.11
Aide hours/ resident / day
3.77
Total nurse hours/ resident / day
0.35
RN hoursweekends
58.0%
Total nursing turnover
58.3%
RN turnover

How full it usually is: this home is certified for 75 beds and averages 60.7 residents a day — about 81% occupied, or roughly 14 beds typically open. It usually has some room. 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 3.77 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 3.20 hrs/resident/day on weekends vs 4.01 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.71 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 58% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

7
deficiencies at the latest standard inspection (2025-08-12)
0
at the previous standard inspection (2023-05-04)

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.

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.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2025-10-29 · 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, medical record review, policy review, and interview, the facility failed to develop and implement a comprehensive, individualized and effective nutrition/hydration plan to prevent weight loss and dehydration for Resident #12. This affected one resident (#12) of three residents reviewed for significant weight loss. The census was 65. Actual harm occurred on 10/01/25 when Resident #12, who had moderate cognitive impairment, was at moderate risk for malnutrition, required cues and assist with eating, and had a care-planned intervention to monitor and provide hydration as prescribed, was assessed to weigh 189.4 pounds representing a 17.3 pound or 8.3 percent (%) severe weight loss in two weeks. The resident was transferred to the hospital (on 10/01/25) and admitted with a change in mental status secondary to dehydration with a five-day hospital stay requiring intravenous fluids. Prior to the hospitalization, the facility failed to ensure ongoing weight monitoring was completed and failed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-22 · tag F0761 — failed to label and store drugs safely — pattern
    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 observations, staff interviews, record review, and review of the facility policy, the facility failed to ensure medications were securely stored. This affected nine residents (#12, #22, #25, #31, #33, #34, #40, #51, and #53). This had the potential to affected nine other residents residing on the memory care care who were independently mobile and had cognitive impairments. The facility census was 62. Findings include: 1. Observation on 01/20/26 at 10:12 A.M. revealed a medication cart unlocked parked on the west hall. On top of the medication cart were eight medication cups with medications (pills) in each individual cup. There were letters written on each cup. There were no staff near or monitoring the medications on top of the unlocked medication cart. Observation on 01/20/26 at 10:15 A.M. revealed Licensed Practical Nurse (LPN) #300 approached the medication cart after exiting a resident room (Resident #1's room). LPN #300 confirmed she left the medication cart unlocked with eight medication cups…

    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 · D2026-01-22 · 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 record review, observations, and resident and staff interviews, the facility failed to ensure the residents who were dependent on staff for toileting hygiene received timely assistance with incontinence care. This affected two (Residents #13 and #42) of three residents reviewed for incontinence care. The facility census was 62.Findings include:1. Record review for Resident #42 revealed an admission date of 10/03/25. Diagnoses included unspecified fracture of the lower end of the right femur, muscle weakness, and need for assistance with personal care.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was cognitively intact. Resident #42 was frequently incontinent of bowel and bladder and was dependent on staff for toileting hygiene.Review of the care plan dated 11/14/25 revealed Resident #42 had an alteration in elimination, and was completely incontinent of bowel and bladder. Interventions included to provide incontinence care as needed. Interview on 01/20/26…

    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 before2025-12-04 · 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, staff interviews, record review, and review of the facility policy, the facility failed to ensure Resident #37's care planned interventions were implemented and skin impairments were identified and treated timely. This affected one (Resident's #37) of four residents reviewed for skin integrity. The facility census was 67.Findings include:Review of Resident #37's medical record revealed an admission date of 10/03/25 and diagnoses included non-infective gastroenteritis and colitis and cerebral palsy.Review of Resident #37's admission Skin assessment dated [DATE] revealed Resident #37 had a stage I pressure ulcer (skin is intact but shows damage from prolonged pressure, appearing as a persistent red, reddish-blue, or purplish area that doesn't turn white (blanch) when pressed), the skin was intact, non-blanchable, and there was erythema (reddening of the skin caused by inflammation).Review of Resident #37's physician orders revealed on 10/04/25, an order to apply house moisture barrier…

    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 · D2025-12-04 · 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, resident and staff interviews, record review, and review of the facility policy, the facility failed to ensure Resident #13's care planned interventions were implemented and failed to ensure Resident #13 had a comprehensive fall evaluation completed timely. This affected one (Resident #13) out of three residents reviewed for falls. The facility census was 67.Findings include:Review of Resident #13's medical record revealed an admission date of 09/04/25. Diagnoses included sepsis, obesity, and type two diabetes mellitus with diabetic neuropathy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Resident #13 had no impairment of the upper and lower extremities and required substantial to maximal assistance for bathing and was dependent for toileting and personal hygiene. Resident #13 required substantial to maximal assistance for the ability to come to a standing position from sitting in a chair, wheelchair or on the side 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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, record review, and review of the facility policy, the facility failed to ensure the residents received timely and appropriate incontinence care. This affected one (Resident's #31) of four residents reviewed for skin integrity. The facility census was 67.Findings include:Review of Resident #31's medical record revealed an initial admission date of 06/10/25 and a re-entry date of 09/03/25. Diagnoses included urinary tract infection, diabetes mellitus without complications, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had moderate cognitive impairment. Resident #31 required substantial to maximal assistance with toileting hygiene, bathing, and personal hygiene and was frequently incontinent of urine and bowel.Review of Resident #31's care plan dated 09/14/25 revealed Resident #31 had an alteration in elimination and was frequently…

    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 · D2025-12-04 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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, pharmacy interview, and record review, the facility failed to ensure Resident #13's physician orders were followed and her medication was available for administration. This affected one (Resident #13) of five reviewed for medication administration. The facility census was 67.Findings include:Review of Resident #13's medical record revealed an admission date of 09/04/25. Diagnoses included obesity - class III and type two diabetes mellitus (DM) with diabetic neuropathy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact and did not reject care during the seven-day assessment look-back period.Review of Resident #13's physician orders dated 11/05/25 revealed Zepbound subcutaneous solution 2.5 milligrams (mg) per 0.5 milliliter (ml), inject one pen needle subcutaneously one time a day every Tuesday for DM. Last week of injection, please notify the Nurse Practitioner (NP).The care plan dated 11/14/25…

    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 · D2025-12-04 · tag F0759 — failed to keep medication error rate low — isolated
    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 observations, review of a manufacturer insert, staff interviews, record review, and facility policy review, the facility failed to ensure a medication error rate of less than five percent (%). Three errors were observed in 27 opportunities resulting in a 11.1% error rate. This affected three (Resident #14, #17 and #31) of three residents observed for medication administration. The facility census was 62. Findings include:1. Record review for Resident #14 revealed an admission date of 09/25/20. Diagnoses included type two diabetes mellitus with hyperglycemia.Review of the care plan dated 10/06/20 revealed Resident #14 was at risk for hypo/hyperglycemia episodes. Interventions included insulin as ordered.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact and had diabetes mellitus.Review of the physician order for Resident #14 revealed an order with a start date 09/01/22 for Novolog FlexPen solution pen injector 100 units per milliliter (ml),…

    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 · D2025-12-04 · 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 record review, staff interviews, pharmacist interview, and review of the facility policy, the facility failed to ensure Resident #101 was free from significant medication errors. This affected one (Resident #101) of five residents reviewed for medication administration. The facility census was 67. Findings include:Review of Resident #101's medical record revealed an admission date of 10/08/25. Diagnoses included Parkinson's Disease without dyskinesia and anxiety. Resident #101 was discharged from the facility on 10/12/25.Review of Resident #101's admission assessment and Baseline Care Plan dated 10/08/25 included Resident #101 was confused and disoriented and unaware of safety needs. Resident #101 was anxious and received antianxiety medication. Review of Resident #101's physician orders dated 10/08/25 revealed alprazolam (Xanax) oral tablet 0.25 milligrams (mg), give one table by mouth every 12 hours as needed for anxiety.Review of Resident #101's Medication Administration Record dated 10/08/25, 10/09/25, 10/10/25, 10/11/25 and 10/12/25 did not reveal alprazolam 0.25 mg,…

    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 before2025-10-29 · 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 record review and interview, the facility failed to ensure wound care was provided for #68's wound. This finding affected one resident (Residents #68) of four residents reviewed for wounds.Findings include:Review of Resident #68's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including paraplegia, chronic respiratory failure, osteomyelitis and major depressive disorder.Review of Resident #68's Skin Integrity Care Plan revealed an intervention dated 12/17/23 to assess pain and provide treatments per the physician's orders.Review of Resident #68's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #68's Pressure Skin Grid dated 10/18/25 revealed a vascular rear left calf wound first identified 10/18/25 which measured 3 cm length by 2 cm width by 0.3 cm depth with small serosanguineous drainage. There was no evidence treatment for the wound was put in place immediately. Review 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-29 · 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 record review and interview, the facility failed to ensure physician orders were obtained and wound care provided for Resident #28's pressure ulcer wounds. This finding affected one resident (Residents #28) of four residents reviewed for wounds.Findings include:Review of Resident #28's medical record revealed the resident was admitted on [DATE] with diagnoses including muscle weakness, other abnormalities of gait and mobility and cerebral palsy.Review of Resident #28's Alteration in Skin Integrity Care plans dated 10/10/25 revealed to assess for pain and provide treatments per the physician's order. Review of Resident #28's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment.Review of Resident #28's Wound #1 Pressure Skin Grid form dated 10/06/25 revealed the resident had a stage one sacrum pressure wound first identified 10/02/25 (earliest stage of skin damage caused by pressure with intact, non-blanchable erythema and/or pain) which…

    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 12 citations
  • Potential for harm · D2025-10-29 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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 #12 received podiatry services in a timely manner. This finding affected one (Resident #12) of four resident records reviewed for auxiliary services.Findings include:Review of Resident #12's medical record revealed the resident was initially admitted on [DATE], sent out to the hospital on [DATE], sent to a rehab center on 08/04/25 and readmitted to the facility on [DATE] with diagnoses including muscle weakness, vascular dementia and epilepsy. Review of Resident #12's auxiliary services form dated 10/14/25 revealed a consent for vision, podiatry, dental and audiology. Observation on 10/27/25 at 9:24 A.M. with Certified Nursing Assistants (CNAs) #806 and #850 of Resident #12's activities of daily living (ADLs) including dressing and incontinence care did not reveal concerns. The resident appeared clean, and the fingernails appeared clean. Further observations revealed the resident's right and left great toes were long 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-08-12 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review, the CASPER Payroll Based Journal Staffing Data Report for the Second Quarter of 2025 (01/01/25 to 03/31/25), staffing schedules, posted staffing information, and staff interview, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 63 residents residing in the facility.Findings include: Review of facility staffing schedules, posted staffing information, and the CASPER Payroll Based Journal Staffing Data Report for the Second Quarter of 2025 (01/01/25 to 03/31/25) revealed there was no evidence of Registered Nurse (RN) coverage eight hours a day on 01/04/25, 03/16/25, 08/02/25, and 08/03/25.Interview on 08/07/25 at 2:45 P.M. with the Administrator verified the facility did not have a the required RN coverage and/or any evidence of eight hours of RN coverage in the facility on 01/04/25, 03/16/25, 08/02/25, and 08/03/25.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-08-12 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to maintain a sanitary dumpster area. This had the potential to affect all residents residing in the facility. The facility census was 63. Findings include:Observation on 08/04/25 at 8:53 A.M. with Dietary Manager (DM) #825 revealed significant debris including gloves, cardboard, and empty medication packaging on the ground surrounding dumpsters. Interview on 08/04/25 at the time of observation with DM #825 confirmed findings and indicated the maintenance department was responsible for ensuring the area remained clean.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-08-12 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    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 the required members of the quality assessment and assurance (QAA) committee participated at least quarterly as required. This had the potential to affect all residents residing in the facility. The facility census was 63. Findings include:Review of Infection Preventionist (IP) Training Certificate dated 10/24/24 revealed IP #833 was the facility's IP. Review of the Quality Assurance and Performance Improvement (QAPI) sign in sheets from 10/16/24, 01/22/25, 04/02/25, 06/18/25, and 07/16/25 revealed no evidence of participation by the facility's IP. Review of undated facility QAPI Plan revealed the QAA committee members included the IP. Interview on 08/12/25 at 10:04 A.M. with the Administrator confirmed IP #833 had not been attending QAPI meetings. The Administrator indicated the facility's IP was also the Receptionist. The Administrator indicated IP #833 provided a report to the Director of Nursing (DON) to present at the QAPI meetings. Interview on 08/12/25 at 10:20 A.M. with IP #833 confirmed she had not been…

    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 · F2025-08-12 · tag F0926 — failed to keep the home smoke-free / fire-safe — widespread
    Have policies on smoking.
    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 ensure a safe smoking environment. This had the potential to affect all residents residing in the facility. The facility census was 63. Findings include: Observation of the resident smoking session on 08/06/25 at 9:09 A.M. revealed Resident #36 and Resident #52 were supervised by Business Office Manager (BOM) #868 in the smoking area at thee back of the building across the parking lot. The two residents began to smoke. There were four cigarette butts in the smoking area. At 9:17 A.M., Dialysis Technician (DT) #921 walked out of the building, stood next to the door, lit a cigarette, and began smoking. DT #921 was observed talking on the phone and flicking her cigarette ashes. There was a trash receptacle next to the facility door, however there was no approved cigarette disposal. DT #921 walked across the parking lot out of view (next to the smoking area) and walked back into the building without a cigarette butt. Interview on 08/06/25 at 9:19 A.M. with DT #921 verified she was smoking next to 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-12 · 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 record review and interview the facility failed to develop a person-centered care plan for smoking. This affected one resident (Resident #36) of 26 reviewed for care planning. The facility census was 63.Findings include: Review of the medical record for Resident #36 revealed an admission date of 07/03/25. Diagnoses included syncope, dysphagia, difficulty in walking, hypertension, anxiety, adult failure to thrive and depression. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #36 had impaired cognition and required supervision from staff for activities of daily living. Review of the care plan dated 07/10/25 revealed no evidence of a care plan for smoking. Review of the smoking assessment dated [DATE] revealed the resident did not require staff assistance or any smoking devices while smoking. Observation of smoking on 08/06/25 at 9:09 A.M. revealed Business Office Manager (BOM) #868 lit Resident #36's cigarette. Resident # 36 was independent with holding his…

    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 · Dcited before2025-08-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 facility Self-Reported Incidents (SRI) and corresponding investigation, and facility policy review, the facility failed to provide timely incontinence care to Resident #9. This affected one resident (#9) out of three residents reviewed for activities of daily living. The facility identified nine residents to be incontinent who resided on the [NAME] unit. The facility census was 63. Findings include: Review of the medical record revealed Resident #9 had an admission date of 09/23/21. Diagnoses included cerebral infraction, a stroke, chronic respiratory failure, gastrostomy, tracheostomy, hemiparesis effecting the right side and heart failure. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #9 was cognitively impaired, non-verbal, and dependent on staff for activities of daily living. The assessment identified the resident was always incontinent of bowel and bladder. Review of a SRI dated 07/14/25 revealed the facility reported an…

    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 before2025-08-12 · 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, interview, and facility policy review, the facility failed to maintain infection control procedures during incontinence care and failed to ensure enhanced barrier precautions (EBP) were maintained during medication administration through a gastrostomy tube. This affected one resident (#9) out of five residents reviewed for infection control. The facility census was 63. Findings include: Review of the medical record revealed Resident #9 had an admission date of 09/23/21. Diagnoses included cerebral infraction, a stroke, chronic respiratory failure, gastrostomy, tracheostomy, hemiparesis effecting the right side and heart failure. a. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #9 was cognitively impaired and dependent on staff for activities of daily living. The assessment identified the resident always incontinent of bowel and bladder. Observation of Resident #9's incontinence care on 08/06/25 at 10:47 A.M. revealed Certified Nursing Assistant…

    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 before2025-01-21 · 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 interview, record review, and policy review, the facility failed to ensure residents received appropriate and timely care after a fall resulting in a fracture. This affected one resident (Resident #19) of three residents reviewed for care. The facility census was 65. Findings Include: Medical record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, repeated falls, urinary retention, bradycardia, arthritis, and high blood pressure. Review of Resident #19's physician's orders revealed an order dated 05/08/23 for hydrocodone - acetaminophen 5-325 milligrams (mg) (an opioid pain medication) three times daily. Review of the Medicare quarterly Minimum Data Set 3.0 assessment, dated 11/21/24, revealed Resident #19 was severely cognitively impaired, needed moderate assistance from staff for toileting and maximum assistance for showering. Review of the nurses' notes revealed on 12/25/24 at 8:01 P.M. Registered Nurse (RN) #219…

    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 before2024-10-16 · 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 review of the medical record, review of medical literature, policy review, and interview with the staff the facility failed to provide a physician ordered treatment for a resident's hormone condition. This affected one resident (#66) of three reviewed for care and treatment. Findings included: Review of the closed medical record revealed Resident #66 was admitted to the facility on [DATE]. Diagnoses included normal pressure hydrocephalus, chronic obstructive pulmonary disease, adult failure to thrive, depression, hypertension, anxiety disorder, overactive bladder, and syndrome of inappropriate secretion of the antidiuretic hormone (SIADH). Review of medical literature from the Cleveland Clinic revealed SIADH happens when a person's body makes excess amounts of antidiuretic hormone (ADH) causing a person's body to retain too much water and can lead to hyponatremia (low levels of sodium in the blood). The condition is treatable. The resident was discharged to the hospital on [DATE] per the family request.…

    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 · Ecited before2024-02-05 · tag F0880 — failed to prevent and control infections — pattern
    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 record review and interview with facility staff and staff from the local Summit County Health Department, the facility failed to maintain an effective infection control program to ensure recommendations by the local health department were implemented/completed to identify and prevent the spread of infection. This affected two residents (#9 and #75) and had the potential to affect 18 additional residents (#8, #12, #19, #21, #22, #25, #27, #28, #37, #39, #51, #54, #55, #56, #58, #59, #65, and #67) who resided on the facility [NAME] Wing. Findings Include: Review of Resident #9's medical record revealed an admission date of 08/19/22 with admitting diagnoses including paraplegia, chronic respiratory failure, resistance to antibiotics, lupus and chronic kidney disease. Record review revealed the resident was discharged on 11/01/23 and re-admitted to the facility on [DATE]. Review of Resident #9's medical record revealed a progress note dated 09/29/23 at 10:26 A.M. which reflected the resident had 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of a self-reported incident and facility investigation and interviews, the facility failed to ensure residents were free from misappropriation. This affected two residents (Residents #25, and #38) of three residents reviewed for misappropriation. The facility census was 69. Findings include: 1. Review of Resident #25's medical record revealed an admission date of 06/16/23. Diagnoses included acute chronic respiratory failure, chronic viral hepatitis C, hypertension, atherosclerotic heart disease, and chronic kidney disease stage three. Review of Resident #25's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/21/23, revealed he had slightly impaired cognition. Resident #25 required extensive assistance by one staff member for bed mobility, and dressing. Resident #25 was set up and supervision only for transfers, wheelchair mobility, toileting, and bathing. Resident #25 was independent with walking and personal hygiene.…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance

“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. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2025-11-21 for 84 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.

Part of a chain

This home belongs to FOUNDATIONS HEALTH SOLUTIONS — 64 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 54.1-1.1 vs chain
Health inspection 2 of 53.9-1.9 vs chain
Staffing 2 of 52.3-0.3 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 63 homes this chain runs (chain average 4.1★, per CMS)
1 of 5Inniswood Health and RehabilitationWesterville, OH 2 of 5Canterbury Villa Of AllianceAlliance, OH 2 of 5Park Health CenterSt Clairsville, OH 2 of 5Tuscany GardensPataskala, OH 2 of 5Veranda Gardens Nursing & Rehabilitation CenterCincinnati, OH 3 of 5Arlington Care CenterNewark, OH 3 of 5Bennington Glen Nursing & Rehabilitation CenterMarengo, OH 3 of 5Cumberland Pointe Care CenterSt Clairsville, OH 3 of 5Emerald Pointe Health And Rehab CtrBarnesville, OH 3 of 5Hickory Ridge Nursing & Rehabilitation CenterAkron, OH 3 of 5Home At Taylor's PointeCincinnati, OH 3 of 5McNaughten Pointe Nursing And RehabColumbus, OH 3 of 5Meadow Grove Transitional CareGrove City, OH 3 of 5The Gables Of Marysville Health And RehabilitationMarysville, OH 3 of 5The Gardens Of Fairfax Health Care CenterCleveland, OH 4 of 5Austin Trace Health And RehabilitationCenterville, OH 4 of 5Batavia Nursing Care CenterBatavia, OH 4 of 5Claymont Health And RehabilitationUhrichsville, OH 4 of 5Crown Pointe Care CenterColumbus, OH 4 of 5Florentine GardensLoveland, OH 4 of 5Hickory Creek Of AthensThe Plains, OH 4 of 5Jefferson Healthcare CenterJefferson, OH 4 of 5Lafayette Pointe Nursing & Rehab CtrWest Lafayette, OH 4 of 5Maria Joseph Living Care CenterDayton, OH 4 of 5Mill Creek Nursing & RehabilitationGalion, OH 4 of 5Respiratory And Nursing Center Of DaytonMoraine, OH 4 of 5Sycamore Run Nursing And Rehab CtrMillersburg, OH 4 of 5Waterview Pointe Nursing & RehabilitationMarietta, OH 4 of 5Woods On French Creek Nursing & Rehab Center TheAvon, OH 5 of 5Admirals Pointe Nursing & RehabilitationHuron, OH 5 of 5Brunswick Pointe Transitional CareBrunswick, OH 5 of 5Capri GardensLewis Center, OH 5 of 5Carington ParkAshtabula, OH 5 of 5Concord Health & Rehab CtrWheelersburg, OH 5 of 5Concord Ridge Health And RehabilitationMentor, OH 5 of 5Country View Of SunburySunbury, OH 5 of 5Darby Glenn Nursing And Rehabilitation CenterHilliard, OH 5 of 5Glen MeadowsHamilton, OH 5 of 5Golden Years Nursing CenterHamilton, OH 5 of 5Highbanks Care CenterColumbus, OH

Showing 40 of 63; 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
COLLERAN, BRIANIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2020
KRYSTOWSKI, JOHNIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2020
FOUNDATIONS HEALTH SOLUTIONS, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2020
JACKSON, CHARLESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/28/2025
PONNAM, HARIKRISHNA CHOUDARYIndividualADP OF THE SNFsince 05/01/2020

CMS files one row per role, so the 12 rows in the source record cover these 5 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.

$9.6M
Net patient revenuemost recent cost report
+8.2%
Operating marginrevenue minus expenses
$1.2M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 22%Medicare 4%Other / private 74%

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$348per resident / day
operating cost
$10,590per month
≈ monthly operating cost
$379per 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 366479. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-12, 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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