Maumee, OH

Lakes Of Monclova Health Campus The

4-star overall rating with 3-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

6935 Monclova Road, Maumee, OH

(419) 866-3030

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Trilogy Health Services

Operator or chain grouping

Approved since

2013-05-23

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

125 facilities

Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars

Changed ownership

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

0.79

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

0.99

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.37

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

4.15

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.78

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.80

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.67

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.67

CMS adjusted RN staffing hours

Adjusted total hours

3.55

CMS adjusted total nurse staffing hours

Case-mix index

1.60

Higher values indicate more complex resident acuity

RN turnover

29%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

34%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,610

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

35.54

Composite VBP score used to determine payment impact.

Payment multiplier

0.9892

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.96

Baseline 19.65% · Performance 20.06% · Measure score 2.96 · Achievement 2.96 · Improvement 0

Healthcare-associated infections

3.47

Baseline 7.65% · Performance 6.80% · Measure score 3.47 · Achievement 3.47 · Improvement 2.70

Total nurse turnover

5.59

Baseline 36.73% · Performance 40.84% · Measure score 5.59 · Achievement 5.59 · Improvement 0

Adjusted total nurse staffing

2.21

Baseline 2.75 hours · Performance 3.57 hours · Measure score 2.21 · Achievement 1.72 · Improvement 2.21

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.06%	10.72% 0.7 pts better	No Different than the National Rate · Eligible stays 203 · Observed rate 9.85% · Lower 95% interval 7.06%
Discharge to community	66.2%	50.57% 15.6 pts better	Better than the National Rate · Eligible stays 204 · Observed rate 59.8% · Lower 95% interval 58.23%
Medicare spending per beneficiary	1.04	1.02 About the same
Drug regimen review with follow-up	98.66%	95.27% 3.4 pts better	Numerator 147 · Denominator 149
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 149
Discharge self-care score	36.52%	53.69% 17.2 pts worse	Numerator 42 · Denominator 115
Discharge mobility score	52.17%	50.94% 1.2 pts better	Numerator 60 · Denominator 115
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 149 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.8%	7.12% 0.3 pts better	No Different than the National Rate · Eligible stays 139 · Observed rate 6.47% · Lower 95% interval 4.66%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 139
Staff flu vaccination coverage	28.57%	42% 13.4 pts worse	Numerator 54 · Denominator 189
Discharge function score	45.22%	56.45% 11.2 pts worse	Numerator 52 · Denominator 115
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 94 · Denominator 94
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 41 · Denominator 41
Resident COVID-19 vaccinations up to date	39.74%	25.2% 14.5 pts better	Numerator 31 · Denominator 78

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	90.1%	92.4% 2.3 pts worse	93.4% 3.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 86.5% · Q2 83.8% · Q3 94.4% · Q4 96.9% · 4Q avg 90.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	92.5%	94.5% 2 pts worse	95.5% 3 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 92.5%
Percentage of long-stay residents experiencing one or more falls with major injury	2.8%	3.3% 0.5 pts better	3.3% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.7% · Q3 2.8% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	13.4%	26.1% 12.7 pts better	11.4% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 15.2% · Q3 14.7% · Q4 9.7% · 4Q avg 13.4%
Percentage of long-stay residents who lose too much weight	7.2%	6.2% 1 pts worse	5.4% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 10.0% · Q3 7.7% · Q4 4.0% · 4Q avg 7.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	21.2%	25.4% 4.2 pts better	19.6% 1.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 16.7% · Q3 17.9% · Q4 28.0% · 4Q avg 21.2%
Percentage of long-stay residents who received an antipsychotic medication	5.0%	11.5% 6.5 pts better	16.7% 11.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 4.2% · Q3 0.0% · Q4 8.3% · 4Q avg 5.0% · 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	4.8%	7.7% 2.9 pts better	16.3% 11.5 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 4.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	4.7%	6.2% 1.5 pts better	14.9% 10.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 10.3% · Q3 3.7% · Q4 0.0% · 4Q avg 4.7% · 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	0.0%	0.5% 0.5 pts better	1.7% 1.7 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 new or worsened bowel or bladder incontinence	28.1%	21.7% 6.4 pts worse	19.8% 8.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 31.0% · Q3 20.8% · Q4 24.5% · 4Q avg 28.1%
Percentage of long-stay residents with pressure ulcers	0.4%	3.7% 3.3 pts better	5.1% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	73.7%	78.1% 4.4 pts worse	81.7% 8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 80.6% · Q2 77.4% · Q3 76.2% · Q4 62.7% · 4Q avg 73.7%
Percentage of short-stay residents who had an outpatient emergency department visit	11.4%	12.5% 1.1 pts better	12.0% 0.6 pts better	Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 11.3% · Expected 11.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.5%	1.2% 0.7 pts better	1.6% 1.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 0.8% · 4Q avg 0.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	76.1%	75.6% 0.5 pts better	79.7% 3.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 76.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.8%	25.1% 1.3 pts better	23.9% 0.1 pts better	Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 23.3% · Expected 23.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-06-06 · Fire 2024-06-06

9 health deficiencies

Top issue: Administration (2 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2021-09-30 · Fire 2021-09-30

5 health deficiencies

Top issue: Administration (1 deficiency)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2019-03-21 · Fire 2019-03-21

16 health deficiencies

Top issue: Resident Assessment and Care Planning (4 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-06-06

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-06-27

F · Potential for more than minimal harm 2024-06-06

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-06-27

F · Potential for more than minimal harm 2021-09-30

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2021-10-22

E · Potential for more than minimal harm 2021-09-30

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2021-10-22

E · Potential for more than minimal harm 2021-09-30

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2021-10-22

E · Potential for more than minimal harm 2019-03-21

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-04-10

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-08

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 2025-10-01

D · Potential for more than minimal harm 2025-03-06

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 2025-03-25

D · Potential for more than minimal harm 2025-03-06

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-25

F · Potential for more than minimal harm 2024-06-06

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2024-07-15

E · Potential for more than minimal harm 2024-06-06

F803 · Nutrition and Dietary Deficiencies

Health

Ensure 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.

Corrected 2024-06-27

E · Potential for more than minimal harm 2024-06-06

F839 · Administration Deficiencies

Health

Employ staff that are licensed, certified, or registered in accordance with state laws.

Corrected 2024-05-23

E · Potential for more than minimal harm 2024-06-06

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-27

D · Potential for more than minimal harm 2024-06-06

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 2024-06-27

D · Potential for more than minimal harm 2024-06-06

F770 · Administration Deficiencies

Health

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected 2024-06-27

D · Potential for more than minimal harm 2024-06-06

F773 · Administration Deficiencies

Health

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Corrected 2024-06-27

E · Potential for more than minimal harm 2021-09-30

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 2021-10-22

D · Potential for more than minimal harm 2021-09-30

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 2021-10-22

D · Potential for more than minimal harm 2021-09-30

F712 · Nursing and Physician Services Deficiencies

Health

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Corrected 2021-10-22

D · Potential for more than minimal harm 2021-09-30

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 2021-10-22

E · Potential for more than minimal harm 2019-03-21

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2019-04-10

E · Potential for more than minimal harm 2019-03-21