13 health deficiencies
Top issue: Infection Control (3 deficiencies)
18 fire-safety deficiencies
Top issue: Emergency Preparedness (10 deficiencies)
Mansfield, OH
2-star overall rating with 2-star inspections with $41,243 in total fines with 13 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
535 Lexington Avenue, Mansfield, OH
(419) 756-7111
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
68
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-04-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.80
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
4.18
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
1,738
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.31
Composite VBP score used to determine payment impact.
Payment multiplier
1.0092
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.31
Baseline 21.88% · Performance 19.55% · Measure score 4.31 · Achievement 4.06 · Improvement 4.31
Healthcare-associated infections
5.30
Baseline 8.55% · Performance 6.49% · Measure score 5.30 · Achievement 4.51 · Improvement 5.30
Total nurse turnover
8.29
Baseline 45.45% · Performance 29.79% · Measure score 8.29 · Achievement 8.29 · Improvement 7.10
Adjusted total nurse staffing
3.83
Baseline 3.38 hours · Performance 4.17 hours · Measure score 3.83 · Achievement 3.83 · Improvement 2.77
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.37% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 21.15% · Lower 95% interval 7.68% |
| Discharge to community | 47.01% |
50.57%
3.6 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 37.5% · Lower 95% interval 31.6% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 93.75% |
95.27%
1.5 pts worse
|
Numerator 60 · Denominator 64 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 64 |
| Discharge self-care score | 22.22% |
53.69%
31.5 pts worse
|
Numerator 8 · Denominator 36 |
| Discharge mobility score | 38.89% |
50.94%
12 pts worse
|
Numerator 14 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 7.81% |
2.29%
5.5 pts worse
|
Numerator 5 · Denominator 64 · Adjusted rate 6.96% |
| Healthcare-associated infections requiring hospitalization | 6.49% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 4.65% · Lower 95% interval 3.66% |
| Staff COVID-19 vaccination coverage | 1.15% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 87 |
| Staff flu vaccination coverage | 6.02% |
42%
36 pts worse
|
Numerator 5 · Denominator 83 |
| Discharge function score | 36.11% |
56.45%
20.3 pts worse
|
Numerator 13 · Denominator 36 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25.81% |
25.2%
0.6 pts better
|
Numerator 8 · Denominator 31 |
Quality measures
| 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 2.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 6.1% |
3.3%
2.8 pts worse
|
3.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 10.2% · Q3 6.0% · Q4 3.8% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
26.1%
25.6 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
6.2%
1.2 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 9.8% · Q3 2.3% · Q4 14.6% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
25.4%
2.3 pts better
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 23.8% · Q3 22.7% · Q4 20.0% · 4Q avg 23.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.3% |
11.5%
1.2 pts better
|
16.7%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 13.2% · Q3 5.4% · Q4 8.1% · 4Q avg 10.3% · 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 | 10.8% |
7.7%
3.1 pts worse
|
16.3%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 13.4% · Q3 8.8% · Q4 4.1% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.0% |
6.2%
1.8 pts worse
|
14.9%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 5.1% · Q3 9.3% · Q4 9.1% · 4Q avg 8.0% · 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 | 32.4% |
21.7%
10.7 pts worse
|
19.8%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.5% · Q2 23.5% · Q3 22.5% · Q4 39.4% · 4Q avg 32.4% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
3.7%
1.7 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.4% · Q3 6.4% · Q4 6.7% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
78.1%
19.6 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.1% · Q4 93.5% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.9% |
12.5%
11.4 pts worse
|
12.0%
11.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 25.0% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
75.6%
24.4 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.3% |
25.1%
11.2 pts worse
|
23.9%
12.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.3% · Observed 41.1% · Expected 27.0% · Used in QM five-star |
Survey summary
Top issue: Infection Control (3 deficiencies)
18 fire-safety deficiencies
Top issue: Emergency Preparedness (10 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Top issue: Resident Rights (5 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-06-04
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-06-04
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-04
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-04
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-04
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-04
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-06-04
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-04
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-04
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-04
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-06-04
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-06-04
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2025-06-04
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2025-06-04
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-06-04
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-06-04
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-06-04
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-04
Fire Safety
Use approved construction type or materials.
Corrected 2022-11-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-12
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-10-12
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-10-12
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-10-12
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-10-12
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-10-12
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-10-12
Inspection history
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-04
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-04
Health
Educate 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.
Corrected 2025-06-04
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-04
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-06-04
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-04
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-06-04
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-04
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-06-04
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-04
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2025-06-04
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-04
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-04
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-26
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-26
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-26
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-06
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-05
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 2022-11-05
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-11-05
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 2022-11-05
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-05
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-11-05
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-11-05
Health
Provide activities to meet all resident's needs.
Corrected 2022-11-05
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-11-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-10-12
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-10-12
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-10-12
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2019-10-12
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 2019-10-12
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-10-12
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 2019-10-12
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2019-10-12
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2019-10-12
Penalties and ownership
Fine · fine $41,243
Fine
5% Or Greater Direct Ownership Interest · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
Mansfield, OH
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
Mansfield, OH
1-star overall rating with 1-star inspections with $130,240 in total fines with 22 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
Mansfield, OH
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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