Strongsville Healthcare And Rehabilitation
18936 Pearl Road, Strongsville, OH 44136 · For profit - Limited Liability company · 99 certified beds · (440) 870-2600 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2024
- 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 recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $27,254 in federal fines (most recent 2024-11-14)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 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 | 1.8% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 2.5% | 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 | 77.2% | 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 | 2.5% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 1.6% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 22.3% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.7% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.3% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 1.9% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.2% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 55.1% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 21.4% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.8% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.98 | 1.73 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.12 | 1.80 | 1.80 | 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.
66.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 170 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 70.6% 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 68 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 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 24% 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 | 66.7%CMS range 59.4–74.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.2%CMS range 9.2–16.2 | 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 | 70.6% | 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 | 70.6% | 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 | 73.5% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.2% | 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 | 0.0% | 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 | 6.5%CMS range 3.4–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.92 | 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 99 beds and averages 91.1 residents a day — about 92% occupied, or roughly 8 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 3.06 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.64 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 3.11 on weekdays — 6% thinner on weekends. RN hours go from 0.84 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% is about the same as 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-12-10 · 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, review of local police report, resident, family, and staff interviews, local police detective interview, review of the National Weather Service forecast, review of the facility Elopement Policy and Procedure, review of camera footage, the facility failed to provide adequate supervision to prevent Resident #37, who had a diagnosis of dementia, post- traumatic stress disorder (PTSD) and severe cognitive impairment, from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious harm, injury, or death when Resident #37 was seen (by camera footage) on 11/23/24 at 11:07 P.M. standing inside the facility in front of the main door when a visiting family member entered from outside, punched in the door code and let Resident #37 out of the building without notifying staff. The resident's whereabouts…
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.
- Immediate jeopardy · J2024-11-14 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, review of an employee personnel file, review of video surveillance, review of a policy report, review of facility policy and interview, the facility failed to ensure Resident #1, a resident with cognitive impairment, was free from staff to resident abuse when Certified Nursing Assistant (CNA) #813 physically abused the resident while providing care. This resulted in Immediate Jeopardy and actual physical and psychosocial harm as a result of the physical abuse incident which occurred on 10/29/24 at approximately 9:30 P.M. when CNA #813 took Resident #1 to the bathroom and the CNA could he heard hitting (audio of skin to skin contact sounding like two smacks) could be heard on the surveillance video and the resident was heard crying out. Continued video surveillance showed CNA #813 coming out of the bathroom with Resident #1 and putting the resident back…
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 · F2026-06-16 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, interviews, and review of facility policies, the facility failed to ensure proper implementation of required infection control practices. Specifically, the facility did not ensure staff consistently followed Enhanced Barrier Precautions (EBP) for residents with indwelling devices, did not properly don and doff required Personal Protective Equipment (PPE) when caring for a resident on droplet isolation for COVID 19, did not use appropriate protective clothing during laundry handling, and did not maintain required procedures to prevent the growth of Legionella bacteria within the facility's water system. These deficient practices affected two residents (Residents #24 and #53) and had the potential to affect all residents in the facility. The facility census was 95.Findings include: 1. Record review for Resident #24 revealed an admission date of 04/02/24. Diagnoses included hemiplegia and hemiparesis following intracerebral hemorrhage affecting the left dominant side,…
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 · F2026-06-16 · tag F0887 — widespreadEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, review of staff education, review of Centers for Medicare and Medicaid (CMS) Regulatory Update dated 05/31/23 titled Educate and Offer and review of the facility policy, the facility failed to educate/offer all eligible staff the COVID 19 vaccination. This had the potential to affect all 95 residents residing at the facility.Findings include:During an interview on 06/15/26 at 9:04 A.M., Certified Nursing Assistant (CNA) #494 stated the fall of 2024 was the last time the facility educated/offered the staff the COVID-19 vaccine.During an interview on 06/15/26 at 10:10 A.M., Infection Preventionist (IP) Registered Nurse (RN) #604 confirmed facility staff were not educated/offered the COVID-19 vaccine in 2025 or 2026 and revealed she did not know she was supposed to. Review of staff education related to COVID-19 on 06/15/26 at 11:58 A.M. with IP RN #604 for 2025/2026 confirmed staff were not educated on COVID-19 vaccine benefits, risks and potential side effects.During an interview on 06/16/26 at 2:03 P.M. with Regional Director of Clinical Operations (RDCO)…
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 · E2026-06-16 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 accurate comprehensive assessments were completed as required. This finding affected three residents (Residents #107, #109 and #111) and had the potential to affect all six residents (Residents #103, #105, #107, #108, #109 and #111) who were transferred to the facility from a sister facility following a fire. The facility census was 95. Findings include: 1. Review of Resident #111's medical record revealed the resident was admitted to the facility 03/13/26 as a transfer from a sister facility with diagnoses including paraplegia, essential hypertension and legal blindness. Review of Resident #111's medical record revealed an admission Minimum Data Set (MDS) 3.0 Comprehensive assessment dated [DATE] with a description of Inactivation of Entry. The MDS did not have evidence that the home conducted a comprehensive, accurate, and standardized assessment of the resident's functional capacity. Telephone interview on 06/15/26 at 12:27 P.M. with Medicaid…
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 · E2026-06-16 · tag F0641 — patternEnsure 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 completed timely. This finding affected three (Residents #107, #109 and #111) and had the potential to affect all six residents (Residents #103, #105, #107, #108, #109 and #111) who were transferred to the facility from a sister facility following a fire. The facility census was 95. Findings include: 1. Review of Resident #111's medical record revealed the resident was admitted to the facility 03/13/26 as a transfer from a sister facility with diagnoses including paraplegia, essential hypertension and legal blindness. Review of Resident #111's medical record revealed the admission Minimum Data Set (MDS) 3.0 Comprehensive assessment dated [DATE] with a description of Inactivation of Entry. The MDS did not reflect the resident's medical, functional, and psychosocial conditions. This included identifying the resident's strengths and needs to maintain or improve the resident's overall status using the appropriate…
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 · D2026-06-16 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the facility policy, the facility failed to ensure care planning conferences were completed at least quarterly. This affected two (Residents #10 and #111) of five residents reviewed for care planning. The facility census was 95. Findings include: 1. Review of Resident #10's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia, bipolar disorder and essential hypertension.Review of Resident #10's medical record revealed a care conference was conducted on 09/30/25.Review of Resident #10's medical record revealed a care conference was conducted on 02/20/26.Review of Resident #10's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment.Telephone interview on 06/14/26 at 10:32 A.M. with Resident #10's family member revealed she had missed the care conference and tried to reschedule, but the facility had never returned her phone calls. Telephone interview on 06/15/26…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate care plans were initiated and updated for two residents (Resident #20 and #24) of 25 residents reviewed for care planning. The facility census was 95.Findings include:1. Record review for Resident #24 revealed an admission date of 04/02/24. Diagnoses included hemiplegia and hemiparesis following intracerebral hemorrhage affecting the left dominant side, neuromuscular dysfunction of bladder and need for assistance with personal care. Review of the physician order for Resident #24 dated 12/15/25 revealed an order for Foley (indwelling) urinary catheter due to obstructive uropathy. An additional order dated 01/06/26 included Enhanced Barrier Precautions (EBP): Gloves and gown to be worn when providing dressing, bathing/showering, transferring, providing hygiene care, changing linens, changing briefs or assisting with toileting.Review of the Annual Minimum Data System (MDS) 3.0 assessment dated [DATE] revealed Resident #24 was cognitively…
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 before2026-06-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records, hospital records, and staff interviews, the facility failed to ensure that appropriate immediate care was provided to Resident #84 following a fall. Staff moved the resident despite her complaints of pain and before notifying the physician or Certified Nurse Practitioner (CNP) for further direction. Resident #84 was later found to have sustained multiple fractures. This affected one resident (Resident #84) of four residents reviewed for accidents. The facility census was 95.Findings include:Record review for Resident #84 revealed an admission date of 10/24/24. Diagnoses included metabolic encephalopathy, dementia, and muscle weakness.Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #84 was rarely or never understood. Resident #84 used a wheelchair for mobility, required supervision or touch assistance for meals, substantial/maximal assistance for toileting hygiene, bathing, bed mobility, lying to sitting on the side of the bed, 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.
- Potential for harm · D2026-06-16 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and review of the facility policy, the facility failed to ensure expired medications were discarded and insulin vials were appropriately dated and discarded as appropriate. This finding affected two (Residents #4 and #19) of two residents identified during the audit of three medication administration carts. The facility census was 95.Findings include:1. Review of Resident #4's medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinson's disease with dyskinesia, essential hypertension and type II diabetes mellitus without complications.Review of Resident #4's physician orders revealed an order dated 03/09/26 (discontinued 03/10/26) for Lantus long-acting insulin inject 10 units subcutaneously at bedtime for diabetes; an order dated 03/10/26 (discontinued 04/20/26) for Lantus long acting insulin inject 10 units subcutaneously at bedtime for diabetes; and an order dated 5/07/26 for Glargine Solostar (Lantus) long acting insulin…
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 · D2025-09-27 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, and staff interview, the facility failed to honor resident preferences for getting out of bed. This affected one (Resident #37) of three residents reviewed for resident rights. The census was 87.Findings Include:Resident #37 was admitted to the facility on [DATE]. Her diagnoses were heart failure, chronic obstructive pulmonary disease, mild protein calorie malnutrition, infection and inflammatory reaction due to internal left knee, acute and chronic respiratory failure, acute kidney failure, pulmonary hypertension, encephalopathy, anemia, atrial fibrillation, cardiomegaly, major depressive disorder, muscle weakness, other bacterial infections of unspecified site, dysphagia, pneumonitis, and diverticulitis of intestine. Review of her minimum data set (MDS) assessment, dated 08/02/25, revealed she was cognitively intact. Review of Resident #37's MDS assessment, section GG, dated 08/02/25, revealed she needed substantial/maximum physical assistance to perform…
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 · E2025-03-06 · tag F0725 — failed to have enough nursing staff — patternProvide 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, record review, interview and review of the facility's' payroll-based journal (PBJ) data, the facility failed to ensure sufficient staffing to meet the needs of residents. This affected seven residents (#1, #6, #8, #34, #49, #76, #82) of eight residents reviewed for sufficient staffing and had the potential to affect all residents. The facility census was 93. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 12/28/22 and a discharge date of 03/05/25. Diagnoses included cellulitis, right below the knee amputation, generalized muscle weakness, difficulty walking, diabetes and chronic pain. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact. He was continent of bowel and bladder, independent in eating, oral and personal hygiene and required supervision for toileting and showering. Review of the fall risk assessment dated [DATE] revealed Resident #1 was not at risk for falls.…
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 12 citations
- Potential for harm · D2025-03-06 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
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 facility policy review, the facility failed to ensure Resident #76 had access to a call light within their functional abilities. This affected one resident (#76) of three reviewed for call light accessibility and had the potential to affect six residents (#18, #21, #27, #61, #74 and #76) identified by the facility as using a modified call light. The facility census was 93. Findings include: Review of the medical record for Resident #76 revealed and admission date of 11/17/23. Diagnoses included Multiple Sclerosis, paralysis of the left side, tremors, and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 was cognitively intact. She required partial to moderate assistance for eating and oral care and substantial or maximum assistance for toileting, showering, and personal hygiene. Review of the care plan dated 02/26/25 revealed Resident #76 who is at risk for a self-care deficit. Interventions included…
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 · D2025-03-06 · 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 record review, interview and facility policy review, the facility failed to ensure Residents #6, #74, and #76 received showers on a consistent basis. This affected three residents (#6, #74 and #76) of three residents reviewed for showers and had the potential to affect all residents. The facility identified all residents required assistance with showers. The facility census was 93. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 02/19/25. Diagnoses included cancer of the urinary system, weakness, and hypertension. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was severely cognitively impaired. He required setup help for eating, supervision for oral and personal hygiene, partial to moderate assistance for showering and was dependent for toileting. Review of the shower sheets dated 02/02/25 through 03/03/25 revealed Resident #6 received a bed bath on 02/20/25, 02/27/25, and 03/3/25. He refused a shower 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 · Dcited before2025-03-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure call lights were answered in a timely manner. This affected five residents (#1, #8, #34, #49 and #82) of six residents reviewed for timely call light response. The facility census was 93. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 12/28/22 and a discharge date of 03/05/25. Diagnoses included cellulitis, right below the knee amputation, generalized muscle weakness, difficulty walking, diabetes, and chronic pain. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact. He was continent of bowel and bladder, independent in eating, oral and personal hygiene, and required supervision for toileting and showering. Review of the fall risk assessment dated [DATE] revealed Resident #1 was not at risk for falls. Observation and interview on 03/05/25 at 1:09 P.M. with Registered Nurse (RN) #207 revealed the activated call…
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 · D2024-12-10 · 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, record review, review of facility video footage, review of the Ohio Department of Health (ODH) Certification and Licensure System (CALS) and review of the facility policy, the facility failed to ensure an allegation of potential neglect was reported to the State Survey Agency as required. This affected one (Resident #37) of six residents reviewed for neglect. Findings include: Review of the medical record for Resident #37 revealed an admission date of 06/02/23 with diagnoses including dementia, chronic kidney disease Stage IV, depression, and post traumatic stress disorder (PTSD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had severe cognitive impairment. Review of a care plan dated 09/03/24 revealed Resident #37 was an elopement/wander risk related to impaired safety awareness. Interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food conversation, television, or books. 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 · Dcited before2024-11-14 · 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, record review, policy review, and interview, the facility failed to ensure Resident #1's care planned interventions were implemented related to wandering behavior and her safety was maintained at all times to prevent elopement from the facility. This finding affected one (Resident #1) of three residents reviewed for accidents and hazards. Findings include: Review of Resident #1's medical record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease with late onset, senile degeneration of the brain and unspecified dementia without behavioral disturbance. The resident resided on the secured memory care unit (SMCU). Review of Resident #1's care plans dated 12/27/22 and revised on 09/16/24 revealed the resident was an elopement risk/wanderer related to the resident's cognitive status and disorientation to place. An intervention dated 12/27/22 stated to assess for fall risk; an intervention dated 12/27/22 to distract resident from wandering by offering pleasant…
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 · D2024-05-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview and facility policy review, the facility failed to ensure a Resident #88 had adequate supply of oxygen to attend an outside doctor's appointment. This affected one resident (#88) of three residents reviewed for respiratory services and had the potential to affect all residents that required oxygen. The facility identified 15 residents (#5, #6, #10, #15, #18, #32, #34, #41, #44, #76, #78, #81, #86, #87, and #88) who were dependent on oxygen. The facility census was 86. Findings include: Review of the closed medical record revealed Resident #88 was admitted to the facility on [DATE] and was discharged on 04/19/24. Pertinent diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, urinary tract infection, anxiety, and obstructive uropathy. Significant orders included, change disposable oxygen equipment weekly, and oxygen at two…
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 · E2024-02-29 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview the facility failed to ensure a home like dining atmosphere on the Memory Care unit. This affected 16 residents (#61, #64, #26, #65, #36, #83, #60, #20, #75, #57, #62, #55, #71, #78, #18, and #59) of 18 residents residing on the unit. The facility census was 86. Findings Include: Observation on 02/28/24 at 12:25 P.M., 16 residents (#61, #64, #26, #65, #36, #83, #60, #20, #75, #57, #62, #55, #71, #78, #18, and #59) were in the dining room eating their lunch. Also present in the dining room were three visiting family members. Maintenance #625 was standing directly across from the dining room. A large white round area was present on the wall. Maintenance #625 had a vacuum which he turned on and started sweeping the wall. After a few minutes the vacuum was turned off. Interview with Maintenance #625 on 02/28/24 at 12:30 P.M. revealed he normally did not vacuum during meals, but it only took a few moments to complete. Maintenance #625 confirmed vacuuming during the meals was disruptive.
- Potential for harm · E2024-02-29 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure tray ticket accuracy and preferences were followed affecting three residents (#23, #61, and #70) observed during dining observations and had the potent to affect four residents (#4, #36, #58, and #74)identified by the facility who received a pureed diet. The facility census was 86. Findings Include: 1. Review of the medical record for Resident #23 revealed an admission date of 03/29/23. Diagnoses included dementia without behavioral disturbance, diabetes mellitus due to underlying condition with diabetic neuropathy, dysphagia (difficulty swallowing), and muscle weakness. Review of the February 2024 physician orders for Resident #23 revealed an active order dated 03/30/23 for low concentrated sweets diet, pureed texture, and thin liquids consistency. 2. Review of the medical record for Resident #70 revealed and admission date of 03/14/23. Diagnoses included type II diabetes mellitus with diabetic chronic kidney disease, dysphagia,…
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 · D2024-02-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, and record reviews the facility failed to ensure Resident #12 and Resident #46's rooms were kept clean and sanitary environment. This affected two residents (#12 and #46) of four residents reviewed for physical environment. The facility census was 86. Findings Include: 1. Observation on 02/26/24 at 9:00 A.M. of Resident #46's room revealed food crumbs on the floor around the bed and recliner. The bathroom had feces on the floor that appeared someone had stepped in it and tracked it in bathroom, feces on the front of toilet seat, the toilet lid, and on the wall behind the toilet. Observation on 02/27/24 at 10:26 A.M. of Resident #46 room revealed all above concerns from the day before were still present. The bathroom and room had not been cleaned. Interview on 02/27/24 at 10:35 A.M. with Housekeeper (HK) #532 and HK#545 stated rooms are to be cleaned daily, which concise of sweeping, mopping, dusting, and cleaning the bathroom. HK #532 and HK #545 stated they did not work on 02/26/24. Interview on 02/27/24 at 10:41 A.M. with Housekeeping Director…
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 before2024-02-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to respond to Resident #61's change in condition. This affected one resident (#61) of 21 residents reviewed for change in condition. The facility census was 86. Findings Include: Resident #61 was admitted to the facility on [DATE] with diagnoses including dementia without behaviors, cirrhosis of the liver, diabetes, heart disease, hypothyroidism, and high blood pressure. Review of the quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #61 was severely cognitively impaired and required extensive care of one to two people for all personal care, including eating. Interview with Resident #61's significant other, who is the resident's Power of Attorney (POA), on 02/26/24 at 12:15 P.M. revealed the resident declined significantly over the last four days. Today was the worst he had been in those four days. The POA said he had increased congestion in his chest and had a history of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-29 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure appropriate diagnoses for the use of psychotropic medications and failed to ensure behaviors were tracked for one resident (#61) of five residents reviewed for psychotropic medication usage. The facility census was 86. Findings Include: Resident #61 was admitted to the facility on [DATE] with diagnoses including dementia without behaviors, cirrhosis of the live, diabetes, heart disease, hypothyroidism, and high blood pressure. Review of the quarterly comprehensive Minimum Data Set 3.0 assessment, dated 01/01/24, revealed Resident #61 was severely cognitively impaired and required extensive care of one to two people for all personal care, including eating. Review of the physician's orders for Resident #61 revealed on 02/09/24 an order was written for Sertraline (an antidepressant) 25 milligrams (mg) once a day for agitation. Sertraline is prescribed for depression. On 02/12/24 an order was written for Seroquel (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 · D2023-09-12 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Resident #50 was free from significant medication errors. This affected one resident (#50) of three residents medication administration. The facility census was 87. Findings include: Review of the medical record for Resident #50 revealed an admission date of 12/08/22. Diagnoses included hypertensive heart disease with heart failure, anemia, history of other venous thrombosis and embolism, acute diastolic (congestive heart failure), depression, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, supraventricular tachycardia, unspecified fall, muscle weakness, difficulty in walking, weakness, repeated falls, unspecified protein-calorie malnutrition, and other lack of coordination. Review of the Minimum Data Set (MDS) assessment, dated 06/16/23, revealed the resident had intact cognition. Resident #50 required limited assistance of two for bed mobility, total with two assists for transfers and toileting, dressing…
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
$27,254 in federal fines across 2 penalties.
- $13,627 — penalty dated 2024-11-14
- $13,627 — penalty dated 2024-11-14
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to PROGRESSIVE QUALITY CARE — 11 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 | 3 of 5 | 2.7 | +0.3 vs chain |
| Health inspection | 2 of 5 | 2.0 | ≈ chain avg |
| Staffing | 2 of 5 | 1.8 | +0.2 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 10 homes this chain runs (chain average 2.7★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| STRONGSVILLE FK HEALTHCARE HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/10/2019 |
| MIKE FLANK TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/09/2022 |
| STRONGSVILLE FK INVESTOR, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/10/2019 |
| FLANK, EITAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/20/2019 |
| FLANK, LIAT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/20/2019 |
| FLANK, MATAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/20/2019 |
| FLANK, SHAUL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/20/2019 |
| GUTTMAN, BEZALEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/20/2019 |
| KATZ, ELIYOHU | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/20/2019 |
| KATZ, YOSEF | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/20/2019 |
| SAUSEN, JOEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/20/2019 |
| SHILLER, DANIEL | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 09/20/2019 |
| PROGRESSIVE QUALITY CARE INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2025 |
| POTOKAR, CARON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/11/2024 |
| THOMAS, CHRISTOPHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2024 |
CMS files one row per role, so the 34 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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.
This home reported $412K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 366491. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-16, 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.