Cycle 1
Health 2024-12-02 · Fire 2024-12-02
27 health deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Dover, OH
Country Club Center I
2-star overall rating with 1-star inspections with $31,371 in total fines with 27 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
860 Iron Avenue, Dover, OH
(330) 343-5568
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Country Club Rehabilitation Campus
Operator or chain grouping
Approved since
1979-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
3.69
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,753
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.73
Composite VBP score used to determine payment impact.
Payment multiplier
0.9918
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.38
Baseline 22.27% · Performance 19.71% · Measure score 4.38 · Achievement 3.71 · Improvement 4.38
Healthcare-associated infections
5.38
Baseline 9.46% · Performance 6.84% · Measure score 5.38 · Achievement 3.34 · Improvement 5.38
Total nurse turnover
2.88
Performance 51.92% · Measure score 2.88 · Achievement 2.88 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.85
Baseline 2.10 hours · Performance 3.33 hours · Measure score 2.85 · Achievement 0.90 · Improvement 2.85
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.52% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 17.19% · Lower 95% interval 8.31% |
| Discharge to community | 57.55% |
50.57%
7 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 52.38% · Lower 95% interval 41.66% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 56.67% |
95.27%
38.6 pts worse
|
Numerator 17 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 32% |
53.69%
21.7 pts worse
|
Numerator 8 · Denominator 25 |
| Discharge mobility score | 20% |
50.94%
30.9 pts worse
|
Numerator 5 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 1 · Denominator 30 · Adjusted rate 3.05% |
| Healthcare-associated infections requiring hospitalization | 6.84% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 6.9% · Lower 95% interval 3.71% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 90 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 28% |
56.45%
28.5 pts worse
|
Numerator 7 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.8
0.7 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.8
0.8 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.2% |
92.4%
9.2 pts worse
|
93.4%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 52.3% · Q2 81.0% · Q3 100.0% · Q4 98.0% · 4Q avg 83.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.6% |
3.3%
7.3 pts worse
|
3.3%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 9.5% · Q3 11.4% · Q4 14.3% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
26.1%
24.2 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.7% · Q3 0.0% · Q4 2.3% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 9.2% |
6.2%
3 pts worse
|
5.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 5.9% · Q3 10.5% · Q4 11.6% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.2% |
25.4%
5.8 pts worse
|
19.6%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 31.4% · Q3 28.2% · Q4 30.2% · 4Q avg 31.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.4% |
11.5%
8.1 pts better
|
16.7%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.7% |
7.7%
3 pts better
|
16.3%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.4% |
6.2%
2.8 pts better
|
14.9%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 2.9% · Q3 0.0% · Q4 2.4% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
0.5%
0.1 pts worse
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.5% |
21.7%
7.8 pts worse
|
19.8%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 25.7% · Q3 19.8% · Q4 33.9% · 4Q avg 29.5% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
3.7%
0.2 pts worse
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 7.3% · Q3 2.7% · Q4 2.3% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.1% |
78.1%
2 pts worse
|
81.7%
5.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 48.5% · Q2 79.7% · Q3 91.8% · Q4 83.1% · 4Q avg 76.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.2% |
12.5%
8.3 pts better
|
12.0%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.2% · Observed 3.8% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.2%
1.3 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.8% · Q3 2.2% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
75.6%
18.2 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 8.5% |
25.1%
16.6 pts better
|
23.9%
15.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 7.7% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-21 · Fire 2022-09-21
13 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-11-26 · Fire 2019-11-26
32 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-02
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-12-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-12-02
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-12-24
E · Potential for more than minimal harm
2024-12-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-24
F · Potential for more than minimal harm
2022-09-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-18
F · Potential for more than minimal harm
2022-09-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-18
F · Potential for more than minimal harm
2022-09-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-18
E · Potential for more than minimal harm
2022-09-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-10-18
E · Potential for more than minimal harm
2022-09-21
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2022-10-18
E · Potential for more than minimal harm
2022-09-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-10
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-31
F · Potential for more than minimal harm
2025-06-30
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-06-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-05-01
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-06
F · Potential for more than minimal harm
2024-12-02
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-12-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-12-02
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-12-24
E · Potential for more than minimal harm
2024-12-02
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-12-24
E · Potential for more than minimal harm
2024-12-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-24
E · Potential for more than minimal harm
2024-12-02
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-02
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-02
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-02
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-02
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-02
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-02
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-12-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-12-24
F · Potential for more than minimal harm
2024-10-24
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-24
D · Potential for more than minimal harm
2024-09-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-08-09
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-06-27
D · Potential for more than minimal harm
2024-06-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-21
G · Actual harm
2023-12-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-13
F · Potential for more than minimal harm
2023-12-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-13
D · Potential for more than minimal harm
2023-12-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-13
D · Potential for more than minimal harm
2023-12-28
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-13
D · Potential for more than minimal harm
2023-12-28
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-01-13
D · Potential for more than minimal harm
2023-12-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-01-13
D · Potential for more than minimal harm
2023-08-16
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-16
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-01
F · Potential for more than minimal harm
2023-06-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-10
F · Potential for more than minimal harm
2023-05-17
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-17
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-17
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-06-08
H · Actual harm
2022-09-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-18
E · Potential for more than minimal harm
2022-09-21
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-10-18
E · Potential for more than minimal harm
2022-09-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-10-18
D · Potential for more than minimal harm
2022-09-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-18
D · Potential for more than minimal harm
2022-09-21
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-10-18
D · Potential for more than minimal harm
2022-09-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-18
D · Potential for more than minimal harm
2022-09-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-18
D · Potential for more than minimal harm
2022-09-21
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2022-10-18
G · Actual harm
2019-11-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-12-19
F · Potential for more than minimal harm
2019-11-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-12-19
F · Potential for more than minimal harm
2019-11-26
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-11-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-11-26
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-11-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-11-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-11-26
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-11-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-11-26
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-11-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-11-26
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-11-26
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-11-26
F772 · Administration Deficiencies
Health
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-11-26
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-11-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-12-19
Penalties and ownership
What sits behind the stars
$26,462
2023-12-28
Fine
Fine · fine $26,462
Fine
$1,764
2023-08-07
Fine
Fine · fine $1,764
Fine
$3,145
2023-07-17
Fine
Fine · fine $3,145
Fine
Ownership
Holland, John
5% Or Greater Direct Ownership Interest · Individual
Holland-Grescock, Teresa
5% Or Greater Direct Ownership Interest · Individual
Harris, Janet
Operational/Managerial Control · Individual
Harris, Janet
Corporate Director · Individual
Harris, Janet
Corporate Officer · Individual
Holland, John
Corporate Officer · Individual
Holland-Grescock, Teresa
Corporate Officer · Individual
Lieber, Paul
Operational/Managerial Control · Individual
Lieber, Paul
W-2 Managing Employee · Individual
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New Dawn Rehabilitation And Healthcare Center
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2-star overall rating with 2-star inspections with 12 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Amberwood Manor
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4-star overall rating with 3-star inspections with 10 recent health deficiencies
#3
Park Village Health Care Center Inc
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4-star overall rating with 3-star inspections with $77,552 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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