Concord Ridge Health And Rehabilitation
9901 Johnnycake Ridge Rd, Mentor, OH 44060 · For profit - Corporation · 88 certified beds · (440) 357-7900 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- 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 payroll-based staffing rating is low (2/5)
- 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) | 2 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 | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 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 | 2.8% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 3.5% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 71.5% | 30.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.4% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 1.3% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 18.6% | 25.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.5% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.2% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.9% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.8% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 87.0% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 39.0% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 23.8% | 12.9% | 12.0% | 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.
50.8% 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 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.3% 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 24 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 50.8%CMS range 38.6–61.8 | 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 | 10.0%CMS range 6.4–15.0 | 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 | 58.3% | 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 | 41.7% | 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 | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 88.1% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.4% | 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 | 2.4% | 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 | 6.9%CMS range 3.5–11.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 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 88 beds and averages 85.3 residents a day — about 97% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. 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 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.63 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 3.01 hrs/resident/day on weekends vs 3.33 on weekdays — 10% thinner on weekends. RN hours go from 0.50 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% 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 11 most serious are shown; the remaining 5 are one tap away and print in full.
- Immediate jeopardy · Jcited before2019-05-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews with staff and residents, review of the medical record, and review of the facility Elopement Risk Assessment Policy and Procedure, the facility failed to provide adequate supervision to prevent the elopement of one resident (Resident #55), who had severe cognitive impairment, a legal guardian and exit seeking behaviors. This resulted in Immediate Jeopardy on 04/22/19 at approximately 9:45 P.M. when Resident #55 exited the facility without staff knowledge. The likelihood of Actual Harm that is Immediate Jeopardy occurred as Resident #55, dressed in dark clothing, was seen pushing his wheelchair along a busy, two lane road at approximately 9:50 P.M. by a staff person driving to work. This affected one of four residents reviewed for elopement risk and wandering behaviors. The facility has identified 25 residents at risk for elopement. The facility census was 91 residents. On 04/25/19 at 1:00 P.M., the Administrator and Corporate Nurse were notified Immediate Jeopardy began 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 · D2024-08-15 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review the facility failed to ensure pre and post dialysis assessments were completed as ordered for Resident #3. This affected one resident (#3) of one resident review for dialysis services. The facility census was 77. Findings include: Review of the medical record for Resident #3 revealed an admission date of 02/03/24. Diagnosis included heart failure, diabetes, end stage renal disease, obesity, anemia, and insomnia. Review of the physician's orders for August 2024 revealed an order for dialysis Monday, Wednesday, and Friday. A dialysis communication form was to be sent with Resident #3 for each visit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. She required supervision or touch assistance for eating and oral hygiene and substantial or maximum assistance for toileting, showering, and personal hygiene. Resident #3 received dialysis. Review of the care plan dated 07/29/24 revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-15 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 record review, interview, and facility policy review the facility failed to ensure clear instruction was in place for the use of opioid pain medication and did not ensure nonpharmacological interventions were attempted prior to the administration of pain medication for Resident #33. This affected one resident (#33) of five residents reviewed for unnecessary medications and had the potential to affect all residents. The facility census was 77. Findings include: Review of the medical record for Resident #33 revealed an admission date of 06/21/24 with diagnoses including heart failure, respiratory failure, asthma, and diabetes. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact. She required set up or clean up help for eating, supervision or touch assistance for oral hygiene, substantial or maximum assistance for personal hygiene and was dependent for toileting and showering. Review of the physician's orders for August 2024 revealed 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.
- Potential for harm · D2023-10-17 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 the interview, record review, and facility policy review the facility failed to ensure Resident #29's repeated concern regarding receiving timely incontinence care was addressed. This affected one resident (#29) out of six residents reviewed for properly addressing complaints/ grievances. The facility census was 81. Findings include: Review of the medical record for Resident #29 revealed an admission date of 08/30/23 with diagnoses including multiple sclerosis, diabetes, need for assistance with personal care, and morbid obesity. Review of the care plan dated 09/11/23 revealed Resident #29 had urinary incontinence and was at risk for altered dignity, skin breakdown, and urinary tract infections. Interventions included checking and providing incontinence care as needed, applying barrier cream after each incontinent episode, and observing and reporting redness, excoriation and/or open areas with incontinence care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 the interview, record review and review of facility policy, the facility did not ensure Resident #29 received timely incontinence care. This affected one resident (Resident #29) out of six residents ( Resident #13, #20, #28, #29, #47, and #72) reviewed for timely incontinence care and had the potential to affect 59 residents (Resident #1, #2, #3, #6, #7, #8, #9, #11, #13, #14, #15, #17, #18, #19, #20,#21, #22, #23, #27, #28, #29, #31, #32, #33, #34, #35, #36, #37, #38, #40, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #54, #55, #56, #59, #60, #61, #62, #63, #65, #68, #69, 70, #71, #72, #74, #75, #78, #80, #82) who were identified as incontinent of bowel and/ or urine. Findings included: Review of medical record for Resident #29 revealed an admission date of 08/30/23 and her diagnoses included multiple sclerosis, diabetes, need for assistance with personal care, and morbid obesity. Review of nursing notes dated from 08/30/23 to 10/17/23 revealed no concerns documented in her medical record regarding…
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 · F2022-06-16 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 88 residents who received meals in the facility. The facility identified Residents #22 and #26 as receiving no food from the kitchen. Findings include: Observation of the kitchen during the initial tour with Corporate Certified Dietary Manager (CDM) #399 on 06/13/22 at 9:55 A.M. revealed the steamer and stove range with food debris and splatter running down sides. Dark blackened grease build up was observed on stove top grates. There was a dark sticky substance on the floor around and behind the steamer, oven, and grill top. Behind the equipment was a food preparation container three quarters full of dark grease like substance on floor and two pieces of foil. Interview with Corporate CDM #399 on 06/13/22 at 10:00 A.M. confirmed all observations. Corporate CDM #399 indicated there was no current dietary manager as the previous manager had quit unexpectedly last week. Follow up observation of the kitchen on 06/14/22 at 12:05 P.M.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-16 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide Resident #77 with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) upon skilled services ending. This affected one resident (Resident #77) of three residents reviewed for liability notices. Findings include: Review of the medical record for Resident #77 revealed and admission date of 06/03/21 with diagnoses including type two diabetes mellitus, osteomyelitis, and aftercare for surgical amputation. The resident was still admitted to the facility. Review of facility beneficiary notice form completed on 06/13/22 by the facility revealed residents discharged from skilled services in the last six months revealed a notice was sent on 02/22/22 to Resident #77 for skilled services ending. Review of the medical record for Resident #77 revealed no evidence the resident received or signed a SNFABN or NOMNC. Interview on 06/14/22 at 9:30 A.M. with Registered Nurse (RN) #398 confirmed no SNFABN or NOMNC was given to Resident #77 upon skilled services…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-16 · 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 record review and staff interview, the facility failed to ensure bed hold notices were given to Resident #28 and Resident #46 and/or their representatives upon transfer to the hospital. This affected two residents (Resident #28 and #46) of two residents reviewed for bed hold notices. Findings include: 1. Review of the medical record for Resident #28 revealed admission date of 03/22/17 and a discharge to the hospital on [DATE]. Review of Resident #28's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 had cognitive impairment. Review of Resident #28's medical record revealed the resident required hospitalization on 06/12/22 for sepsis. The medical record identified no evidence the resident or resident representative was provided written notification of a bed hold upon Resident #28's transfer to the hospital. Interview on 06/16/22 at 9:09 A.M. with Corporate Nurse #394 verified the facility did not provide a bed hold notice to Resident #28.2. Review of the medical record revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 interview and record review, the facility failed to provide bed baths/showers routinely and as scheduled. This affected two residents (Resident #5 and Resident #21) of five residents reviewed for activities of daily living. Findings include: 1. Review of Resident #5's medical record revealed an admission date of 01/15/21 and diagnoses including acute and chronic respiratory failure, prediabetes, lymphedema, morbid obesity, hypertension and depression. Review of Resident #5's quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively intact and was totally dependent on two or more staff for bathing. Review of the undated 300/400 shower schedule revealed Resident #5 was to be bathed Mondays and Thursdays on evening shift. Review of 30 days of shower data for Resident #5 revealed one bed bath was recorded on 05/14/22 (Saturday). No refusals were marked on the shower sheet and no data was available for 05/16/22 (Monday), 05/19/22 (Thursday), 05/23/22 (Monday), 05/26/22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement appropriate fall interventions related to assistance with toileting to prevent Resident #49's falls. This affected one resident (#49) of four residents reviewed for falls. Findings include: Review of the medical record for Resident #49 revealed admission date of 05/27/20 with diagnoses including fracture of left femur, left femur intramedullary nailing, unspecified falls, muscle weakness, difficulty walking, lack of coordination, altered mental status, vascular dementia, restlessness and agitation, age related osteoporosis, and history of left hip fracture in 2016. Review of care plan initiated 06/05/20 revealed Resident #49 was at risk for falls related to confusion, history of falls, incontinence, medications, and impaired gait. Interventions included bed against wall, deep perimeter mattress to bed, encourage resident to wear bilateral hipsters, non-skid strips by bed, reinforce use of call light, utilize pillows to position…
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 on observation, interview, and record review, the facility failed to ensure medications were stored in a secured manner. This affected one (Resident #9) resident, and had the potential to affect two (Residents #15 and #140) cognitively impaired and independently mobile residents who reside on the same floor as Resident #9. The facility also failed to ensure expired medications were disposed of as required. This had the potential to affect 15 residents who have their blood sugars tested in the facility, and any residents who may receive a suppository or tuberculin testing in the facility. The facility census was 91 residents. Findings include: 1. On 04/23/19 at 11:05 A.M., the door to Resident #9's room was observed shut. The surveyor knocked on the door, and entered when the resident gave permission. As the surveyor spoke with the resident, who had been dozing in her bed, the surveyor observed a small plastic cup of pills and tablets sitting on the bedside table. One of the tablets appeared to be a large tablet resembling a potassium chloride (treats low levels of potassium)…
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 5 citations
- Potential for harm · D2019-05-02 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report a possible occurrence of neglect to the State agency when a resident eloped from the facility. This affected one (Resident #55) resident reviewed for elopement. The facility census was 91 residents. Findings include: Review of the record of Resident #55 revealed he was admitted to the facility on [DATE] with diagnoses including alcohol dependence, unsteadiness, muscle weakness, alcoholic peripheral neuropathy, altered mental status, and visual hallucinations. The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #55 was severely cognitively impaired; he did not have behaviors; and he required limited to extensive assistance of staff for activities of daily living. Review of the record revealed an elopement risk assessment completed on 03/28/19 which indicated the resident was at high risk for elopement due to his diagnoses of alcoholism and delusions, as well as making verbal statements that he wanted to leave. 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 F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the necessary equipment and/or services were provided for comfort and possible prevention of a decline in range of motion. This affected one (Resident #5) of one resident reviewed with limited range of motion The facility census was 91 residents. Findings include: Review of the medical record for Resident #5 revealed an admission date of 08/09/16, and diagnoses including dementia, cerebral infarction, hemiplegia and hemiparesis, and contracture of the left lower leg and left hand. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/17/19, revealed the resident had severely impaired cognition. Resident #5 required the extensive assistance of two staff members for bed mobility, dressing, toilet use and personal hygiene. The resident was totally dependent on staff for transfers and locomotion. The resident needed supervision for eating. Review of the plan of care with a start date of 01/13/17 and a review date of 04/22/19 revealed there was a care plan for the left lower leg contracture,…
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 F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure oxygen therapy was provided, monitored, and documented as ordered. This affected one (Resident #134) of three residents reviewed for oxygen therapy. The facility census was 91 residents. Findings include: Review of the medical record for Resident #134 revealed an admission date of 04/11/19, and diagnoses including acute respiratory failure with hypoxia, acute on chronic congestive heart failure, bipolar disorder, autistic disorder, and mild intellectual disabilities. Review of the admission Minimum Data Set (MDS) assessment, dated 04/18/19 revealed the resident had moderately impaired cognition. Resident #134 required extensive assistance for bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. The resident was on oxygen therapy. Review of physician orders revealed there was an order beginning on 04/11/19 for continuous oxygen at 2-4 liters per nasal cannula to maintain blood oxygen saturation greater than 88%. The order included the instructions to record oxygen…
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 F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, the facility failed to ensure the outside dumpster garbage disposal area was maintained in a clean manner. This had the potential to affect all facility residents. The facility census was 91 residents. Findings include: Observation of the facility outside dumpster area with Dietary Coordinator (DC) #451 on 04/22/19 10:32 A.M. revealed two of the lids had been left open and some plastic gloves, a cardboard box and other garbage were observed on the ground around the dumpster. DC #451 verified the above observations at the time of discovery.
- No harm found · Bcited before2024-08-15 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and staff interview, the facility failed to provide timely notification of Medicare non-coverage and inform residents of the costs of continuing non-covered services. This affected two residents (#43 and #80) of three reviewed for beneficiary notification. The facility census was 77. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 01/15/21 and readmission date of 03/31/24. Diagnoses included acute and chronic respiratory failure with hypoxia, morbid obesity, chronic obstructive pulmonary disease, type two diabetes mellitus, and congestive heart failure. Review of the progress note dated 06/11/24 at 5:31 P.M. revealed Resident #43 was provided the Notice of Medicare Non-Coverage (NOMNC) and planned to stay in the facility long-term. The note did not specify whether the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) was provided. Review of the NOMNC, not dated, revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.1 | +0.9 vs chain |
| Health inspection | 5 of 5 | 3.9 | +1.1 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 4.3 | -0.3 vs chain |
The other 63 homes this chain runs (chain average 4.1★, per CMS)
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 / manager | Type | Role | Since |
|---|---|---|---|
| COLLERAN, BRIAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2023 |
| KRYSTOWSKI, JOHN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2023 |
| FOUNDATIONS HEALTH SOLUTIONS, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/04/2025 |
| WEST, BETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2023 |
| DHILLON, VARINDER | Individual | ADP OF THE SNF | since 12/01/2023 |
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.
This home reported $1.0M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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 366011. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-15, 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.