Indian Lake Rehabilitation Center
14442 State Route 33 West, Lakeview, OH 43331 · For profit - Corporation · 40 certified beds · (937) 843-4929 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.1% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 4.4% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 32.7% | 30.1% | 6.5% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.6% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 4.1% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 33.7% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.1% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.9% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.2% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 85.0% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.9% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 23.0% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.40 | 1.73 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.25 | 1.80 | 1.80 | 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.
62.1% 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 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 38 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 62.1%CMS range 46.1–71.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 6.3–13.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 42.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 42.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 18.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 87.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.4%CMS range 3.6–10.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.70 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 40 beds and averages 35.6 residents a day — about 89% occupied, or roughly 4 beds typically open. It runs fairly full. 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 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.88 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 3.04 hrs/resident/day on weekends vs 3.54 on weekdays — 14% thinner on weekends. RN hours go from 1.06 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · D2023-10-23 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, resident interviews, agency staff interview, Community Member interview and review of policy, the facility failed to report an allegation of abuse to the state agency. This affected one (#63) of three residents reviewed for potential abuse. The facility census was 34. Findings include: Observation of the main entrance of the facility revealed the residents who smoke come out to the front of the building and sit outside of the main entrance to smoke. There is a small handicap ramp in the entrance about 4 feet wide extended from the cemented area to the parking lot. Interview on 10/23/23 at 10:00 A.M. to 10:05 A.M., with Community Member #1 revealed she does not work at the facility and received this information from a friend via text form with pictures. Community Member #1 described the picture was of a black woman in a wheelchair smoking, being pushed down the ramp into the parking lot and agency State Tested Nurse Assistant (STNA) laughing with a caption. Community Member #1 revealed she called the facility two times and reported the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-23 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, resident interviews, agency staff interview, Community Member interview and review of policy, the facility failed to investigate and an allegation of abuse. This affected one (#63) of three residents reviewed for potential abuse. The facility census was 34. Findings include: Observation of the main entrance of the facility revealed the residents who smoke come out to the front of the building and sit outside of the main entrance to smoke. There is a small handicap ramp in the entrance about 4 feet wide extended from the cemented area to the parking lot. Interview on 10/23/23 at 10:00 A.M. to 10:05 A.M., with Community Member #1 revealed she does not work at the facility and received this information from a friend via text form with pictures. Community Member #1 described the picture was of a black woman in a wheelchair smoking, being pushed down the ramp into the parking lot and agency State Tested Nurse Assistant (STNA) laughing with a caption. Community Member #1 revealed she called the facility two times and reported the incident. The first…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-16 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — the official record, unedited, may be distressing
Based on medical record review and staff interview the facility failed to ensure physician orders were followed. This effected one Resident (#180) of seven residents reviewed for laboratory services. The facility census was 35. Findings include: Review of the medical record of Resident #180 revealed a physician order dated 11/17/21 for a basic metabolic panel (BMP) to be monitored every Wednesday for four weeks. Review of the medical record revealed no results of any BMP as ordered. Review of the progress notes revealed no documentation of the physician being notified the labs were not completed. Review of the medical record revealed no laboratory reports for the BMPs. Interview on 12/16/21 at 11:00 A.M. with Director of Nursing (DON) provided verification of the lack of BMP results. DON stated they had not been obtained as ordered. This deficiency substantiates complaint #OH00128116.
- Potential for harm · F2019-05-02 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on personnel file record review, staff interview and review of the facility's tuberculosis risk assessment, the facility failed to complete tuberculosis (TB) skin testing or questionnaire was completed upon hire and/or annual. This affected eight of eight employees reviewed for TB testing. This had to the potential to affect all 36 residents residing in the facility. Findings include: Review of the personnel file for State Tested Nurse Aide (STNA) #108 revealed a hire date of 04/16/19. There was no documentation that a tuberculosis skin test or questionnaire was completed. Review of the personnel file for STNA #109 revealed a hire date of 02/01/19. There was no documentation that a tuberculosis skin test or questionnaire was completed. Review of the personnel file for STNA #110 revealed a hire date of 12/01/16. There was no documentation that a annual tuberculosis skin test or questionnaire was completed. Review of the personnel file for STNA #111 revealed a hire date of 12/01/16. There was no documentation that a annual tuberculosis skin test or questionnaire was completed.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-05-02 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 observation, staff interview, and review of facility policy, the facility failed to ensure medications were stored in a safe and secure manner for one (#90) resident residing in the facility. This had the potential to affect 15 (#3, #5, #6, #9, #11, #12, #14, #17, #18, #21, #22, #24, #25, #28 and #37) cognitively impaired mobile residents in the facility. The facility census was 36. Finding include: On 05/02/19 at 2:35 P.M., an open box was observed beside the telephone at the nurse's station. The box was labeled with the name of Resident #90 and contained five individual blister dose packs of an anticoagulant medication (Eliquis 2.5 milligrams (mg.)) and one blister pack of an antianginal medication (Isordil 30 mg. half tablet). The nursing station had two entry points without doors or other type of barrier, and there was no barrier to prevent residents or the public from reaching over the top of the desk. There was no staff present at the nursing station at the time of the observation. When questioned, Registered Nurse (RN) #102 and #106 stated Resident #90 was being…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-05-02 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility's Antibiotic Use Tracking Sheet, staff interview and policy review, the facility failed to ensure eight residents (#2, #4, #8, #10, #14, #20, #21 and #29) of 28 residents reviewed for antibiotic stewardship had active signs and symptoms of infection prior to prescribing antibiotics. The facility census was 36. Findings include: Review of the facility's January 2019 Antibiotic Use Tracking Sheet revealed Resident #29 had a dry scaly scalp with no date of onset. The physician prescribed Bactrim DS (antibiotic ) for 14 days. Four residents (#2, #10, #14 and #20) displayed symptoms of a cough without any other signs and symptoms. There was no diagnostic testing completed for these four residents. Three of the residents (#2, # 10 and #20) were placed on a Z- Pack ( Zithromycin antibiotic) for four days. Resident #14 was placed on Augmentin 875-125 milligrams (mg.) for seven days. The tracking sheet stated Resident #21 had a possible urinary tract infection. The signs and symptoms were listed as increased urination , increased confusion, and increased…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-02 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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, staff interview and review of facility policy, the facility failed to have consistent documentation of Advanced Directive status across all medical records for Resident #1 and #29) and failed to have any documented evidence of Advanced Directive status for Resident #36. This affected three (#1, #29 and #36) of four residents were reviewed for Advance Directives. The facility census was 36. Findings include: 1. Medical record review for Resident #1 revealed an admission date of 01/08/19. Diagnoses included mixed hyperlipidemia, essential hypertension, primary generalized osteoarthritis, other idiopathic scoliosis, atrial fibrillation and cerebral palsy. Review of the electronic medical record for Resident #1 on 04/30/19 at 9:25 A.M. reflected the profile page to be silent to any advance directive code status. Review of the physician orders also found no advance directive code status. Review of the hard medical record found a Do Not Resuscitate (DNR) form dated 01/08/19 that had been signed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-02 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide written notification to a resident's representative of a transfer to the hospital. This affected one (#22) of one resident reviewed for hospitalization. The facility census was 36. Findings include: Record review for Resident #22 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dysphagia, chronic kidney disease, dementia without behaviors, and cognitive communication deficit. Review of the nursing progress notes, dated 03/16/19, revealed the resident had an unwitnessed fall in her room sustaining a laceration to her head. She complained of severe pain in her left hip following the fall. The resident was transferred to the hospital and admitted for surgical repair of a left hip fracture. Review of the medical record revealed there was no evidence the resident's representative was given a written notice for the resident's transfer to the hospital on [DATE]. Interview on 05/02/19 at 3:40 P.M. with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-02 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 and staff interview, the facility failed to provide a bed hold notice to a resident's representative when the resident was transferred to the hospital. This affected one (#22) of one resident reviewed for hospitalization. The facility census was 36. Findings include: Record review for Resident #22 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dysphagia, chronic kidney disease, dementia without behaviors, and cognitive communication deficit. Review of the nursing progress notes, dated 03/16/19, revealed the resident had an unwitnessed fall in her room sustaining a laceration to her head. She complained of severe pain in her left hip following the fall. The resident was transferred to the hospital and admitted for surgical repair of a left hip fracture. Review of the medical record revealed there was no evidence the resident's representative was given a bed hold notice when the resident transferred to the hospital on [DATE]. Interview on 05/02/19 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-02 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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
Based on record review and staff interview, the facility failed to ensure a comprehensive person centered care plan was written for Resident #25 and the correct code status for Resident #29's care plan. This affected two (#25 and #29) of 17 residents reviewed for care plans. The facility census was 36. Findings include: 1. Medical record review for Resident #25 revealed an admission date of 01/05/19. Diagnoses included anxiety disorder. Review of the current physician orders, dated 03/05/19, revealed the resident had an order to receive an antianxiety medication named Buspar five milligrams (mg.) twice daily. Review of a Minimum Date Set (MDS) assessment, dated 04/09/19, revealed the resident had a diagnosis of anxiety with the use of antianxiety medication. Review of the comprehensive care plan, initiated 01/05/19 and revised 04/09/19, revealed it was silent to the resident's diagnosis of anxiety disorder with no planned interventions to address this need, and did not address the use of the psychoactive antianxiety medication. Interview with MDS Coordinator #102 on 05/01/19 at 1:30…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · D2019-05-02 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 medical record review, resident and staff interview, and policy review, the facility failed to have care conferences on a quarterly basis and invite a resident to attend a care conference. This affected one (#32) of two residents reviewed for care conference attendance. The facility census was 36. Findings include: Record review for Resident #32 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hypertension, gastro-esophageal reflux disease, chronic obstructive pulmonary disease, and dementia with behavioral disturbances. Review of the annual comprehensive Minimum Data Set (MDS) assessment, dated 04/05/19, revealed the resident has no cognitive impairments. He was assessed to have no delusion, hallucinations, or any behavioral symptoms. Review of the social service progress note, dated 01/23/19, stated Social Service Designee #101 approached the resident concerning a care conference and the resident refused stating no, he didn't want to go. He stated to just find him 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.
- Potential for harm · D2019-05-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and review of hospice contracts, the facility failed to ensure collaboration and communication between the facility and hospice entities for two (#5 and #31) of two residents reviewed for hospice services. The facility identified four residents currently receiving hospice services. The facility census was 36. Findings include: 1. Medical record review for Resident #31 revealed an admission date of 03/05/19. Diagnoses included dementia with behaviors. Review of the current physician orders for May 2019 reflected an order to admit to Hospice services for end stage dementia. The medical record contained a Hospice contract signed by the resident's responsible party, dated 04/12/19. On 05/01/19 at 10:50 A.M. a Hospice nurse from Hospice Entity #105 was observed at the nurse's station writing orders and talking with staff Registered Nurse (RN) #106. After the hospice nurse left the nurse's station, an interview with RN #106 found that the hospice nurse speaks with facility staff during her visits, but leaves no progress notes in the medical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and staff interview, the facility failed to ensure Resident #5 received tube feeding as ordered by the physician. This affected one (Resident #5) of one resident reviewed for tube feeding. This facility identified one resident who received tube feeding. Findings include: Review of the medical record for Resident #5 revealed an admission date of 10/23/14 with diagnoses including multiple sclerosis, paraplegia, developmental disorder, aphasia, and cerebral palsy. Review of the resident's physician orders, dated 08/28/17, revealed a diet order for nothing by mouth (NPO). Further review of the physician orders, dated 01/15/19, revealed Fibersource, a tube feeding formula, was to run at 65 milliliters per hour for a total of 22 hours each day and water was to run at 30 milliliters per hour while the tube feeding was running via gastrostomy tube (a tube used to provide nutrients and fluid into the stomach). Review of the Medication Administration Record (MAR) for Resident #5 revealed a new tube feeding bag was to be hung at 6:00 P.M. Observation 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.
- Potential for harm · D2019-05-02 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to act upon a physician's response to the pharmacist recommendation for a resident. This affected one (#33) of five residents reviewed for unnecessary medication. The facility census was 36. Findings include: Medical record review for Resident #33 revealed an admission date of 03/30/15. Diagnoses included Alzheimer's disease, major depressive disorder, insomnia, psychosis, schizophrenia, and bipolar disorder current episode depressed severe with psychotic features. Review of current physician orders, dated May 2019, revealed the resident had orders for the following psychoactive medications: antidepressants Trazadone 25 milligrams (mg.) daily, mirtazapine 15 mg. at bedtime, and citalopram 20 mg. daily. Review of a pharmacy medication regimen consultation report, dated 04/02/19, revealed the pharmacist noted Resident #33 was receiving three antidepressants concomitantly, and recommended the physician to consider discontinuing Trazodone while continuing mirtazapine at bedtime and while monitoring for re-emergence 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.
- Potential for harm · D2019-05-02 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident and staff interview, the facility failed maintain three resident's wheelchairs in safe operating condition. This affected three (#18, #23 and #37) of 17 residents reviewed for safe operating equipment. The facility identified 20 residents dependent on wheelchairs for locomotion. The facility census was 36. Findings include: On 05/01/19 at 1:00 P.M., an observation of Resident #23 revealed the resident was propelling in his wheelchair in the hallway. On the medial side of the left arm rest, the covering was torn with jagged rough edges. The resident was wearing a short sleeve shirt. The resident stated the arm of his wheelchair was torn and needed repair. On 05/01/19 at 1:10 P.M., an observation of Resident #37 revealed the resident was in a wheelchair in the dining room. The covering of the right arm of his wheelchair was torn in multiple areas causing the covering to have rough edges. On 05/01/19 at 1:12 P.M., an observation of Resident #18 revealed the resident was in a wheelchair in the dining room. The covering of the left arm of his wheelchair was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2019-05-02 · tag F0607 — failed to have anti-abuse policies — widespreadDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on personnel record review, staff interview, and facility policy review, the facility failed to ensure reference checks were completed for new hires. This affected six of six employees reviewed for completion of reference checks. This had the potential to affect all 36 residents. Findings include: Review of the personnel record for State Tested Nurse Aide (STNA) #108 revealed a hire date of 04/16/19. There was no documentation of reference checks being completed. Review of the personnel record for STNA #109 revealed a hire date of 02/01/19. There was no documentation of reference checks being completed. Review of the personnel record for STNA #112 revealed a hire date of 06/12/18. There was no documentation of reference checks being completed. Review of the personnel record for Director of Nursing (DON) #113 revealed a hire date of 04/22/19. There was no documentation of reference checks being completed. Review of the personnel record for Maintenance Supervisor #114 revealed a hire date of 04/10/19. There was no documentation of reference checks being completed. 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.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to SABER HEALTHCARE GROUP — 126 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.9 | +2.1 vs chain |
| Health inspection | 5 of 5 | 2.6 | +2.4 vs chain |
| Staffing | 4 of 5 | 2.2 | +1.8 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 125 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 125; 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 / manager | Type | Role | Since |
|---|---|---|---|
| SABER HEALTHCARE HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/01/2016 |
| WIW DYNASTY LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/01/2023 |
| VOLPE, BENJAMIN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | since 03/01/2019 |
| WEISBERG, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 03/01/2019 |
| NICOLUZAKIS, GREGORY | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 03/01/2019 |
| SABER GOVERNANCE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2019 |
| SHG MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2019 |
| HOHLEFELDER, JASON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/19/2022 |
| SENTER, ALAYNA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/05/2019 |
| BENJAMIN N. VOLPE FAMILY DYNASTY TRUST (DATED DECEMBER 29, 2020) | Organization | ADP OF THE SNF | since 01/01/2023 |
| BNV DYNASTY LLC | Organization | ADP OF THE SNF | since 01/01/2023 |
| CITRIN COOPERMAN ADVISORS LLC | Organization | ADP OF THE SNF | since 12/01/2016 |
| DECANTED WILLIAM I. WEISBERG FAMILY DYNASTY TRUST (DATED SEPT 30, 2020 | Organization | ADP OF THE SNF | since 01/01/2023 |
| INDIAN LAKE RE GROUP, LLC | Organization | ADP OF THE SNF | since 12/01/2016 |
| FULMER, GREGG | Individual | ADP OF THE SNF | since 04/02/2018 |
CMS files one row per role, so the 24 rows in the source record cover these 15 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.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $648K paid to related parties — landlords or management companies under common ownership — equal to about 15% 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. 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365666. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-20, 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.