Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Anchor Lodge Nursing Home Inc during CMS and state inspections, most recent first.
A resident with a feeding tube and NPO status was documented in the medical record as receiving medications by mouth, when in fact all medications were administered via the feeding tube. Multiple nursing staff were aware of the resident's NPO status but continued to record oral administration on the MAR, resulting in inaccurate medical records.
Staff did not consistently wear required PPE, specifically gowns, while providing high-contact care to a resident with a feeding tube on enhanced barrier precautions for MDRO risk. Both a CNA and an LPN provided care without gowns despite facility policy and care plan directives, and acknowledged awareness of the requirements during interviews.
A resident with bipolar disorder, depression, and anxiety had a prior PASRR that did not identify SMI because no psychotropic meds had been prescribed at that time. Later, the resident was ordered trazodone and quetiapine, and the MDS documented antidepressant and antipsychotic use, but there was no evidence the facility referred the resident for another PASRR review. Interviews with the Admissions/Social Services Director and Administrator confirmed a new PASRR should have been completed after psychotropic meds were started.
Medication administration errors exceeded the allowed rate after surveyors observed three errors in 31 opportunities. An LPN gave two medications to one resident via G-tube instead of PO as ordered, and another LPN gave only one sertraline tablet instead of the ordered three tablets. Interviews confirmed staff did not fully verify the order, MAR, label, dose, and route, despite facility policy requiring the medication rights to be followed.
Inaccurate Medical Record Documentation for Medication Administration
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for a resident with multiple diagnoses, including dysphagia following a stroke, gastrostomy status, and a physician order for nothing by mouth (NPO). Despite the resident's NPO status and use of a feeding tube, the medical record and Medication Administration Record (MAR) documented that several medications, including Keppra, Lamictal, and Tramadol, were administered by mouth. Observations confirmed that these medications were actually given via the feeding tube, not orally as recorded. Interviews with nursing staff, including LPNs and an RN, revealed that all were aware the resident received medications through the feeding tube and not by mouth, but continued to document administration as oral on the MAR. The Clinical Coordinator and Director of Nursing acknowledged the discrepancy, stating that the medical record was inaccurate and that clarification should have been sought from the physician regarding the medication orders. The facility's policy required accurate reference to current orders and reporting of errors, which was not followed in this instance.
Failure to Use Proper PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow proper infection prevention and control protocols for a resident with a feeding tube who was on enhanced barrier precautions (EBP) due to increased risk of multidrug-resistant organism (MDRO) acquisition. The resident, who had oropharyngeal dysphagia following a stroke and was severely cognitively impaired, required EBP as indicated in the care plan and physician orders. The care plan specifically directed staff to don appropriate personal protective equipment (PPE), including gowns and gloves, prior to high-contact care activities such as incontinence care and feeding tube management. Despite these directives, observations revealed that a certified nursing assistant (CNA) and a licensed practical nurse (LPN) both provided high-contact care to the resident without wearing gowns, although gloves were used. The CNA provided incontinence care and the LPN administered medication via the feeding tube without donning gowns, contrary to facility policy and the resident's care plan. Both staff members acknowledged awareness of the EBP requirements but cited reasons such as forgetting or being nervous for not following protocol. Interviews with facility leadership confirmed that staff were expected to wear gowns during such care activities for residents on EBP.
Failure to Complete PASRR After Psychotropic Medications Were Ordered
Penalty
Summary
The facility failed to ensure Resident #6 received a PASRR when the resident had diagnoses of bipolar disorder, major depressive disorder, and anxiety disorder and was later prescribed psychotropic medications. The resident’s medical record showed a prior PASRR dated 01/13/2022 that indicated diagnoses of panic or other severe anxiety disorder, bipolar disorder, and depression, and stated the resident had not been prescribed any psychotropic medications within the last six months, so the screen did not identify SMI. The resident’s quarterly MDS with an ARD of 11/05/2025 showed a BIMS score of 15, indicating the resident was cognitively intact, and also documented use of antipsychotic and antidepressant medications during the seven-day look-back period. The record further showed physician orders for trazodone 25 mg at bedtime for depression, started 07/26/2024, and quetiapine fumarate 12.5 mg at bedtime for bipolar disorder, started 10/30/2024. Care plan documentation also reflected antidepressant and antipsychotic medication use. There was no documented evidence that the facility referred Resident #6 for a PASRR review when the psychotropic medications were ordered. During interviews, the Admissions/Social Services Director stated that a new PASRR review should be completed when a resident is newly prescribed psychotropic medication, but she was unsure why it had not been done for this resident. The DON stated she had nothing to do with PASRRs, and the Administrator stated another PASRR should have been completed after the resident was later prescribed psychotropic medication, but she was not sure why it was not completed.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. During surveyor observation, there were 31 medication administration opportunities and three medication errors, resulting in a 9.68 percent error rate. The deficiency affected two of six residents observed during medication administration, and the facility census was 91. Resident #32 had diagnoses including asthma, major depressive disorder, and epilepsy. The resident had orders for Keppra 500 mg by mouth every morning and at bedtime and vitamin C 500 mg by mouth every morning, but during medication administration observation, an LPN gave both medications via gastrostomy tube instead of by mouth. The LPN stated the resident took nothing by mouth and that everyone knew medications had to be given via the feeding tube, but also stated she should have read the order completely and notified the unit manager for clarification. Resident #11 had diagnoses including hypertension, dementia, and coronary artery disease. The resident had an order for sertraline 25 mg with instructions to give 75 mg by mouth in the morning, but during observation an LPN prepared and administered only one 25 mg tablet instead of three tablets. The LPN later stated she should have double checked the order, MAR, and medication label. Interviews with the Clinical Coordinator and DON confirmed staff should verify the medication label against the order and follow the five rights of medication administration, including right resident, medication, dose, route, and time.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lorain
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Pointe Health Care | 1.3 mi | ★★★★★ | 0 | 0 |
| Oak Hills Nursing Center | 1.6 mi | ★★★★★ | 4 | 0 |
| Autumn Aegis Nursing Home | 2.1 mi | ★★★★★ | 0 | 0 |
| Amherst Manor Nursing Home | 3.7 mi | ★★★★★ | 0 | 0 |
| Kingston Health Center Of Vermilion | 6.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.