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The Pavilion At Stow For Nursing And Rehabilitatio

3700 Englewood Drive, Stow, OH 44224 · For profit - Corporation · 51 certified beds · (330) 688-1828 Medicare & Medicaid certified

Call the home — (330) 688-1828 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Feb 2019
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (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 (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (72%) runs well above the national median (45%)
  • its last standard health inspection was over 3 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4465 Darrow Rd · (330) 688-9501 · Call to confirm hours
Pharmacy
2086 Graham Rd · (330) 688-4372 · Call to confirm hours
Grocery
3732 Darrow Rd · (330) 686-5280 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased2.2%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight2.9%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms55.6%30.1%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.6%3.2%3.3%better
Long-stay residents whose ability to walk worsened2.1%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication28.8%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine90.9%94.5%95.3%typical
Long-stay residents with pressure ulcers2.1%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control32.5%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table16.7%8.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication3.9%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine30.0%75.6%79.4%worse
Short-stay residents rehospitalized after admission37.8%24.9%22.6%worse
Short-stay residents with an outpatient ER visit32.4%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.

0.36U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened9.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.67
RN hours/ resident / day
0.67
LPN hours/ resident / day
1.83
Aide hours/ resident / day
3.16
Total nurse hours/ resident / day
0.41
RN hoursweekends
72.1%
Total nursing turnover
73.3%
RN turnover

How full it usually is: this home is certified for 51 beds and averages 44.0 residents a day — about 86% occupied, or roughly 7 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 3.16 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.93 hrs/resident/day on weekends vs 3.25 on weekdays — 10% thinner on weekends. RN hours go from 0.77 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 72% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

5
deficiencies at the latest standard inspection (2023-08-21)
3
at the previous standard inspection (2021-10-14)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 3 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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · Dcited before2024-11-06 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, medical record review and review of facility policy, the facility failed to ensure call lights were within reach and accessible to residents. This affected three residents (#11, #12, and #36) of six residents reviewed for call light placement. The facility census was 44. Findings include: 1. Review of Resident #11's medical record revealed an admission date of 08/09/24 with diagnoses that included, but not limited to, cerebral infarction, muscle weakness, difficulty in walking and glaucoma. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 09/04/24, revealed Resident #11 was cognitively intact and required staff assistance for all activities of daily living (ADLs). Observation on 11/06/24 at 8:32 A.M. revealed Resident #11 was lying in bed. The call light was on the floor and not within the resident's reach. 2. Review of Resident #12's medical record revealed an admission date of 08/30/24 with diagnoses that included, but not limited to, muscle weakness, difficulty in walking and amaurosis fugax (a painless temporary loss…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-04-17 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure sufficient staffing to meet the needs of the residents. This affected Resident's #1, #6, #10, #21, #23 and had the potential to affect all the residents residing in the facility. The facility census was 36. Findings include: 1. Review of Resident #21's medical record revealed an admission date of 04/01/21 and diagnoses included chronic respiratory failure with hypoxia, type two diabetes mellitus with diabetic nephropathy, and a personal history of urinary tract infections. Review of Resident #21's Quarterly Nutrition Evaluation dated 07/17/23 included Resident #21's diet order was low concentrated sweets, no added salt. Resident #21 was at risk for dehydration. Further review revealed to encourage fluids with and between meals for Resident #21, and might need to prompt, remind, cue and, or present fluids to Resident #21 to assure adequate fluid intake and hydration status. Review of Resident #21's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-04-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review and review of the facility policy the facility failed to ensure a sanitary kitchen. This had the potential to affect all 36 of 36 residents residing in the facility. Findings include: Observation on 04/15/24 at 7:05 A.M. of the kitchen with Dietary Director (DD) #131 revealed two large packages of frozen ground meat were placed in a large sink full of cold water. There was no observation of running water used to thaw the frozen meat. DD #131 confirmed the frozen meat was in the sink of cold water and no water was running into the sink where the frozen meat was. Observation on 04/15/24 at 7:10 A.M. with [NAME] #132 of the cooler in the kitchen revealed a metal rack was placed in the middle of the cooler and a tray on the metal rack full of small plastic containers with pears in most of the cups and cottage cheese in a smaller amount of cups revealed none of the small plastic containers had lids or plastic wrap covering them. Further observation revealed the small plastic containers were undated. [NAME] #132 confirmed the food in 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-17 · tag F0807 — failed to offer suitable drinks — pattern
    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident's #21 and #23 received water timely and per their preference. This affected two residents (Resident #21 and #23) out of three residents reviewed for receiving water timely and had the potential to affect 12 residents (Resident's #1, #2, #3, #6, #8, #13, #17, #21, #23, #26, #27, #30) residing on the 200 nursing unit. The facility census was 36. Findings include: 1. Review of Resident #21's medical record revealed an admission date of 04/01/21 and diagnoses included chronic respiratory failure with hypoxia, type two diabetes mellitus with diabetic nephropathy, and a personal history of urinary tract infections. Review of Resident #21's Quarterly Nutrition Evaluation dated 07/17/23 included Resident #21's diet order was low concentrated sweets, no added salt. Resident #21 was at risk for dehydration. Further review revealed to encourate fluids with and between meals for Resident #21, and might…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-17 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #6's room was sanitary. This affected one resident (Resident #6) out of three residents reviewed for sanitary environment. The facility census was 36. Findings include: Review of Resident #6's medical record revealed an admission date of 01/10/20 and diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, anxiety disorder, and vascular dementia, unspecified severity with other behavioral disturbances. Review of Resident #6's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment. Resident #6 was always incontinent of urine and bowel. Resident #6's upper and lower extremities had impairment on both sides, Resident #6 used a wheelchair, and Resident #6 was dependent for toileting hygiene. Review of Resident #6's care plan with a target date of 05/28/24 included Resident #6 had…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review the facility failed to ensure Resident #10's physician ordered diagnostic test was scheduled timely. This affected one resident (Resident #10) out of three residents reviewed for appointments. The facility census was 36. Findings include: Review of Resident #10's medical record revealed an admission date of 06/24/23 and diagnoses included chronic kidney disease, stage four, morbid obesity, major depressive disorder and type two diabetes mellitus with diabetic polyneuropathy. Review of Resident #10's physician orders dated 07/25/23 revealed Resident #10 would have a sleep study done on 07/27/23 at 8:30 P.M. at a sleep study location. Resident #10 needed to have a shower and be free of any lotions, oils, no caffeine or chocolate after 12:00 P.M. on 07/25/23. No OTC (over the counter) medication, no nail polish. Resident #10 could bring a pillow and wear loose, comfortable clothing. Review of Resident #10's progress notes dated 07/28/23 at 5:39 A.M. revealed Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident's #1 and #10 received incontinence care timely. This affected two residents (Resident's #1 and #10) out of three resident's reviewed for incontinence care. The facility census was 36. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 08/30/18 and diagnoses included dementia without behavioral, psychotic, mood disturbance and anxiety, type two diabetes mellitus with hyperglycemia, and major depressive disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had severe cognitive impairment. Resident #1 was frequently incontinent of urine and bowel. Resident #1 was dependent on staff for toileting hygiene. Review of Resident #1's care plan with a target date of 07/11/24 included Resident #1 had episodes of bladder and bowel incontinence related to the need for assistance with ADL's (Activity of Daily…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-08-21 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to maintain the kitchen stove/oven in a safe operating manner. This had the potential to affect all 38 residents receiving food from the kitchen. The facility identified one resident (Resident #139) who received enteral nutrition. The census was 39. Findings include: Observation of the kitchen on 08/14/23 at 10:14 A.M. revealed the facility's primary stove/oven was a six burner flat top with all but one temperature control knob for the stove's top burners missing and one of the oven temperature control knobs was missing. There was a rust-like substance on the oven doors and sides of the stove/oven. Interview on 08/14/23 at 10:15 A.M. with Kitchen Manager #108 confirmed the stove /oven control knobs were missing because the oven had malfunctioned and melted most of the oven control knobs off the stove. Kitchen Manager #108 produced one of the stove control handles that was melted on the bottom half. The Kitchen Manager stated the oven had been malfunctioning so the temperature in the oven would randomly shoot up to 500 degrees…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-21 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, resident and staff interviews, and review of the facility policy, the facility failed to provide a clean home like environment for 27 residents (Resident #1, #2, #3, #4, #8, #9, #10, #11, #12, #14, #16, #17, #18, #19, #20, #22, #24, #25, #27, #28, #29, #30, #31, #33, #34, #35, and #140) of 39 residents who participated in meals and/or activities outside of their rooms. The facility census was 39. Findings include: Observation on 08/14/23 from 9:30 A.M. through 11:30 A.M. revealed there were four halls where residents resided and traveled on throughout the facility. The nursing station was located in the center leading to each hall. All halls were carpeted including surrounding the nursing station. The carpeting in all halls including surrounding the nurses station was embedded with black dirt, grime, food, and red fluid spills. The carpeting was soiled from the beginning of each carpeted area through the end. Many areas on each hall had large black areas that were so embedded with dirt or other substances, that the fibers of the carpet were no longer visible.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure residents were provided clean, intact linens for their bed. This affected one resident (Resident #30) of one residents reviewed for linens. The facility census was 39. Findings include: Record review for Resident #30 revealed an admission date of 07/20/23. Diagnosis included pneumonia, pleural effusion, retention of urine, muscle weakness, and need for assistants with personal care. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #30 had moderate cognitive impairment and required extensive assistance of two for bed mobility, transfers, dressing, and toilet use. Resident #30 used a wheelchair for mobility, had an indwelling catheter, and was frequently incontinent of bowel. Observation and interview on 08/14/23 at 10:01 A.M. with Resident #30 revealed he had been asking for clean linen. Resident #30 stated that sometimes at night his catheter would leak and his sheets and blankets would get wet with urine. Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2023-08-21 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policy, the facility failed to ensure Preadmission Screening and Resident Review (PASARR) Identification Screens were accurate and timely upon admission. This affected one resident (Resident #35) of three residents reviewed for PASARR. The facility census was 39. Findings included: 1. Review of Resident #35's medical record revealed she was admitted to the facility on [DATE] with diagnoses including bipolar disorder (entered 06/07/23), and major depressive disorder (entered 06/07/23). Review of Resident #35's admission Medicare Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 was moderately cognitively impaired. Resident #35 had no behaviors exhibited. Resident #35 required limited assist of one for bed mobility, transfers, independent with eating, and extensive assist for toilet use. Record review of the admission Medicare five-day Minimum Data Set, dated [DATE] for Resident #35 revealed Resident #35 was moderately…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to re-assess nutritional status and implement interventions to prevent further significant weight loss. This affected one resident (Resident #29) of three residents reviewed for nutrition. The facility census was 39. Findings include: Record review for Resident #29 revealed an admission date of 06/13/23. Resident #29 had a hospital readmission on [DATE] and returned to the facility on [DATE]. An additional hospital readmission occurred on 07/17/23 and the resident returned to the facility on [DATE]. Diagnosis included enterocolitis due to clostridium difficile (c-diff), unspecified protein calorie malnutrition, cerebral infarction (stroke), dysphagia (difficulty or discomfort when swallowing), need for assistance with personal care and muscle weakness. Record review of the physician progress note dated 06/16/23 completed by Primary Care Physician #165 revealed Resident #29 had severe malnutrition. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-10-14 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to maintain the ice machine in a clean and sanitary manner. This finding had the potential to affect thirty of thirty-one residents (except Resident #18) who receive fluids in the facility. The facility census was 31. Findings include: Observation on 10/12/21 at 12:34 P.M. revealed that when the ice ejector inside the ice machine was wiped off by Kitchen Manager #801, the paper towel had black debris on the towel. Interview on 10/12/21 at 12:40 P.M. with Kitchen Manager #801 confirmed the ice machine had not cleaned since 03/2021 and it was not maintained in a sanitary manner.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-14 · tag F0623 — isolated
    Provide 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 record review and interview, the facility failed to ensure Resident #35 received the appropriate discharge notices. This finding affected one (Resident #35) of one resident reviewed for hospitalization. The facility census was 31. Findings include: Review of Resident #35's medical record revealed the resident was admitted on [DATE] and discharged to the hospital on [DATE] with diagnoses including anxiety disorder, heart failure and atherosclerotic heart disease. Review of Resident #35's medical record did not reveal evidence the resident or the resident's representative was notified in writing the reason for the discharge in an easily understood language. The medical record also did not reveal evidence the ombudsman was notified of the resident's discharge to the hospital. Interview on 10/13/21 at 1:31 P.M. with Business Office Manager (BOM) #802 confirmed Resident #35 and/or the resident's representative were not notified of the reason for the discharge in an easily understood language. BOM #802 also…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-02-14 · tag F0756 — failed to review each resident's drug regimen — widespread
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview and policy review, the facility failed to ensure a licensed pharmacist did monthly pharmacy reviews for the month of January 2019. This had the potential to affect all 48 residents in the facility. Findings include: Review of Residents #28, #32, #33, #34, #35, and #38 records revealed no monthly pharmacy reviews were completed for the month of January 2019. Interview on 02/12/19 at 1:41 P.M. the Director of Nursing (DON) revealed the facility changed pharmacies 01/01/19. The DON verbalized he had called the pharmacy requesting a consulting pharmacist to come to the facility. The DON verified the facility has not had a consulting pharmacist review resident medications since 01/01/19. Telephone interview on 02/12/19 at 2:20 P.M. with Chief Executive Officer (CEO) for the facilities pharmacy revealed that a pharmacist resigned, and a consultant pharmacist was not sent to the facility in January 2019. He verified that the monthly medication review for January 2019 was not completed and would send someone to come out to do the monthly reviews. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2019-02-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, policy review and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 45 out of 48 residents who ate meals in the facility's kitchen. Three residents (Residents #4, #5, and #22) received enteral nutrition and did not receive meals from the kitchen. Findings include: Observations during the initial tour of the kitchen on 02/10/19 from 8:14 A.M. through 8:30 A.M. revealed one case of nectar thickened dairy drink, one container of nectar apple juice, one case of honey tea and one case of Styrofoam containers on the floor in the dry storeroom. Two bakers' racks were dirty with dried food, one rack had fruit pies on sheet trays for the upcoming meal and the other had a sheet tray with sliced apples portioned in dessert cups, five salads with diced chicken, and one plain salad. Storage bins of sugar and rice had food splatter on the outside. The side of the six burner stove had grease running down the side. The table the steamer was placed had dried food and crumbs on it. The microwave…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-02-14 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, policy review and interview, the facility failed to ensure a dignified dining experience for residents that ate in the main dining room. Residents (#2, #3, #8, #11, #12, #14, #15, #16, #17, #19, #24, #28, #29, #30, #31, #33, #38, #40, #41, #43, #46, #152, #199, and #247) ate meals in the dining room sitting at three long tables. State Tested Nursing Assistants (STNA) served entrees to the residents by tickets switching from table to table with not all residents served by table. This affected all 24 residents that ate in the main dining room. Findings include: Observations during meal service for lunch in the main dining room on 02/10/19 from 11:35 A.M. through 12:50 P.M. revealed that residents were served by STNAs by tickets switching from table to table with not all residents served by table. This was verified by Registered Dietitian #148 at 12:50 P.M. Interview with Registered Dietitian on 02/10/19 at 12:50 P.M. verified that all residents should be served table to table. Review of policy entitled, The Briarwood Dining Room Meal Service, dated 11/18,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-02-14 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure comprehensive assessments were accurate. This finding affected four (Residents #5, Resident #21, Resident #27 and Resident #42's) of twenty-three resident records reviewed for comprehensive assessments. The facility census was 48. Findings include: 1. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), spastic quadriplegia, major depressive disorder, and anxiety. The record further revealed the resident took nothing by mouth. Review of Resident #5's medical record revealed the Minimum Data Set (MDS) 3.0 assessment, dated 11/09/18, revealed the resident was assessed as needing extensive assistance of one person for feeding. Further record review revealed the resident received all nutrition through a tube feeding and was totally dependent on staff for tube feedings. On 02/12/19 at 4:57 P.M. an interview with MDS Nurse #154…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-02-14 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure care plans reflected resident needs regarding medications and diagnoses. This affected four (Resident #28, Resident #32, Resident #34, and Resident #38) of twenty-three resident records reviewed. The facility census was 48. Findings include: 1. Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including congestive heart failure, osteoporosis, chronic kidney disease, obesity, sleep apnea, repeated falls, diabetes, atrial fibrillation, high blood pressure, and major depressive disorder. Review of Resident #28's physician orders and medication administration records revealed the resident received Novolog, Levemir, and Humalog (insulin's) in addition to Eliquis (an anticoagulant) and Hydrochlorothiazide (a diuretic). Review of Resident #28's care plan revealed no focus areas, goals, or interventions for the anticoagulant, diuretic, and insulin medications the resident was receiving.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-02-14 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to accommodate a proper fitting mattress for Resident #42. This affected one resident out of the 48 residents that were screened during Phase I of the annual survey. Findings include: Review of Resident #42's medical record revealed an admission date of 03/31/17 and a readmission date of 01/09/18. Diagnoses included heart failure, chronic kidney disease, diabetes mellitus, hypertension, and peripheral vascular disease. An admission height was obtained on 01/09/18 of 74.0 inches. Review of Resident #42's Minimum Data Set (MDS) 3.0 assessment, dated 01/20/19, revealed the resident exhibited moderate cognitive impairment. Observation on 02/10/19 at 9:40 A.M. Resident #42 was lying in bed with his heels resting on the footboard of the bed and stated he was uncomfortable. Licensed Practical Nurse (LPN) #113 verified that Resident #42 had his heels resting on the foot board of the bed and stated that she had told them Resident #42 needed a bigger bed before. Observation on 2/11/19 at 1:21 P.M. Social Worker (SW) #143…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-02-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, policy review, and review of the wheelchair cleaning schedule, the facility failed to ensure resident care equipment was maintained in a clean and sanitary manner. This affected Resident #22 and Resident #43. The facility census was 48. Findings include: On 02/12/19 at 9:45 A.M. observation revealed dried food items on the bars and seat of a black electric wheelchair in the hallway and on Resident #43's wheelchair. On 02/12/19 at 9:45 A.M. Minimum Data Set Nurse (MDS Nurse) #154 verified a black electric wheelchair in the hallway and the wheelchair of Resident #43 had dried food on the bars and seat of the chairs. On 02/12/19 at 9:49 A.M. an interview with Licensed Practical Nurse (LPN) #113 verified dried food on the bars and seat of Resident #43's wheelchairs. On 02/12/19 at 11:07 A.M. observation of Resident #22's tube feeding equipment revealed the pole holding the tube feeding pump and the tube feeding bag with solution had a moderate amount of dried tan material (same color as the tube feeding solution infusing) on the base of the pole. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-02-14 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a thorough investigation was completed for Self-Reported Incident (SRI), tracking number 162350. This affected one of two SRI's reviewed during the annual survey. The facility census was 48. Findings revealed: Review of the facility investigation for SRI tracking number 162350 revealed only the comments and information sent to the State of Ohio on 10/14/18. There were no interviews of facility staff and residents, and no resident assessments. On 02/13/19 at 2:55 P.M. an interview with the Director of Nursing (DON) verified the lack of investigation for SRI tracking number 162350. The DON verbalized he was not employed at this facility at the time of the incident on 10/14/18 and verbalized attempts to reach the previous DON by phone were unsuccessful. The DON verbalized there was no additional information regarding the incident on 10/14/18 other than what is noted in the self-reported incident report submitted to the State of Ohio. On 02/14/19 at 11:20 A.M. Social Worker (SW) #143 verified the Weekend Manager on Duty…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-02-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to properly transfer a resident resulting in a fall with fracture. This affected one (Resident #21) of five residents reviewed for falls. The facility census was 48. Findings Include: Review of the medical record revealed Resident #21 was admitted to this facility on 06/16/18. His admitting diagnoses included presence of cardiac pacemaker, history of falling, paroxysmal atrial fibrillation, hypertension, and Alzheimer's disease. Review of the Fall Risk Assessment, dated 06/16/18, revealed the resident was a high risk for falls. Review of the resident's care plan, dated 06/18/18, revealed the resident was at risk for falls related to impaired mobility, unsteady gait, and history of falls. An intervention dated 06/18/18 stated the resident should be transferred with the use of a gait belt and assist of one. Review of the nurse's note dated 07/31/18 at 8:10 P.M. revealed an unknown state tested nursing assistant (STNA) #900 was getting the resident out of his chair. She stood him up with the walker and no gait belt. She needed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-02-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure urinary catheter changes were completed per the physician's order. This affected one resident (Resident #35) out of one resident reviewed for urinary catheters. The facility census was 48. Findings Include: Review of the medical record revealed Resident #35 was admitted to this facility on 01/06/18. His admitting diagnoses included obstructive sleep apnea, neurogenic bladder, cardiac pacemaker, quadriplegia, and stage IV pressure ulcers on the left and right buttocks (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/10/19, the resident was alert and oriented with no cognitive impairment. Functionally, he required extensive assistance for most of his activities of daily living. The bowel and bladder section of this MDS showed that the resident did have an indwelling urinary catheter. Review of the physician's orders revealed on 07/12/18 the physician ordered a 16 French…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-02-14 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure bowel and bladder tracking was consistently documented for Resident # 5 and Resident #197. This affected two residents reviewed for incontinence. The facility census was 48. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 07/30/18. Diagnoses included constipation, dysphagia, anxiety disorder, major depressive disorder, insomnia, encounter for attention to gastrostomy, cognitive communication deficit, and spastic quadriplegic cerebral palsy. Review of Resident #5's Minimum Data Set (MDS) 3.0 assessment, dated 11/09/18, revealed the resident was rarely understood and required extensive assistance with Activities of Daily Living (ADL). Resident #5 was always incontinent of bowel and bladder. Review of the bowel and bladder tracking revealed Resident #5 did not have a bowel movement for five days from 02/08/19 to 02/12/19. The Director of Nursing (DON) verified the lack of documented evidence of a bowel movement. Observation and interview on 2/13/19 at 1:15 P.M. with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-02-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure proper hand hygiene protocol was maintained during dressing changes of pressure ulcers. This affected one resident (Resident #35) out of five residents reviewed for pressure ulcers. There was a total of eight residents in the facility who received dressing changes. The facility census was 48. Findings Include: Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. His admitting diagnoses included obstructive sleep apnea, neurogenic bladder, cardiac pacemaker, quadriplegia, and stage IV pressure ulcers on the left and right buttocks (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/10/19, the resident was alert and oriented with no cognitive impairment. Functionally, he required extensive assistance for most of his activities of daily living. This MDS…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2021-10-14 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, observation and facility record review, the facility failed to maintain a clean and safe environment in resident care areas with stained carpet and unstable dining room tables. This had the ability to affect all residents residing in the facility. Facility census was 31. Findings Include: Observation of the resident hallways revealed the carpeting in the entire area had numerous carpet stains in the areas where the residents live. This was observed throughout the survey process from 10/12/21 through 10/14/21. Interview with the Director of Nursing (DON) on 10/13/21 at 2:50 P.M. revealed the facility had the carpets steam cleaned approximately six weeks earlier and Housekeeping would spot clean when necessary. Interview with the Administrator on 10/14/21 at 11:33 A.M. revealed on 07/22/21 invoice #6200 revealed a local carpet cleaning company came to the facility on [DATE] and 07/22/21 to deep clean the facility's carpeting. The carpet was pre-sprayed, then steam cleaned and deodorized…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has plan of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to THE PAVILION GROUP — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.8-0.8 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 1 of 51.8-0.8 vs chain
Quality measures 3 of 54.0-1.0 vs chain
The other 5 homes this chain runs (chain average 2.8★, per CMS)

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 / managerTypeRoleShareSince
STOW GROUP HOLDINGS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 02/06/2025
ACM ASHEM HOLDINGS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF56%since 02/06/2025
EVANS, TYLERIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/06/2025
SCHONFELD, SIMCHAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF23%since 02/06/2025
MOERMAN, RAFAELIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/06/2025
KELLER, STEPHENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/06/2025
NPNH1 LLCOrganizationADP OF THE SNFsince 02/06/2025
SHS KEREN LLCOrganizationADP OF THE SNFsince 02/06/2025
STOW PROPERTY HOLDINGS, LLCOrganizationADP OF THE SNFsince 02/06/2025
STOW PROPERTY ROLL UP, LLCOrganizationADP OF THE SNFsince 02/06/2025
STOW PROPERTY, LLCOrganizationADP OF THE SNFsince 02/06/2025
BIRNBAUM, EZRAIndividualADP OF THE SNFsince 02/06/2025
DY, JOSEIndividualADP OF THE SNFsince 02/06/2025
HIRSCH, SHAYEIndividualADP OF THE SNFsince 02/06/2025

CMS files one row per role, so the 20 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

7 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.

$4.3M
Net patient revenuemost recent cost report
-11.0%
Operating marginrevenue minus expenses
$521K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 72%Medicare 3%Other / private 25%

About 72% 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 $521K 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

$332per resident / day
operating cost
$10,107per month
≈ monthly operating cost
$299per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365858. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-08-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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