Heatherdowns Rehab & Residential Care Center
2401 Cass Rd, Toledo, OH 43614 · Lucas County · 84 certified beds · avg 77 residents/day · certified since Jun 15, 1989
Part of chain: LIONSTONE CARE (24 facilities, chain avg rating 2.5★)
2/5
Health inspection rating (on-site)
2
Serious findings on record
$0
Fines, last 3 years
2.67
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Sep 18, 2025 · F-0627 · triggered by a complaint
The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely.
Why it matters: A rushed or poorly planned move can leave a resident somewhere that can't meet their needs.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 10, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Nov 16, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 29, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (54)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 6, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| May 6, 2026 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint |
| Jan 28, 2026 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Jan 28, 2026 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Jan 28, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Nov 26, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Sep 18, 2025 | ▲ G · Actual harm, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Feb 10, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 10, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 10, 2025 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Feb 10, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 10, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Feb 10, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Feb 10, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Feb 10, 2025 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| Feb 10, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Dec 31, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Nov 19, 2024 | D · Potential for harm, one-off | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint |
| Oct 16, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Apr 18, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 28, 2024 | D · Potential for harm, one-off | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint |
| Feb 28, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Dec 11, 2023 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Dec 11, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. · from a complaint |
| Dec 11, 2023 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. · from a complaint |
| Nov 16, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Oct 10, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 22, 2022 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Sep 22, 2022 | E · Potential for harm, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Sep 22, 2022 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Sep 22, 2022 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Sep 22, 2022 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Sep 22, 2022 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Sep 22, 2022 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Sep 22, 2022 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Sep 22, 2022 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 22, 2022 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Sep 22, 2022 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Sep 22, 2022 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Sep 22, 2022 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Sep 22, 2022 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 12, 2019 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 12, 2019 | E · Potential for harm, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Sep 12, 2019 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Sep 12, 2019 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Sep 12, 2019 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Sep 12, 2019 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. |
| Sep 12, 2019 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Sep 12, 2019 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Sep 12, 2019 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Sep 12, 2019 | D · Potential for harm, one-off | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (14 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 10 | 0 | F |
| 2022 | 14 | 0 | F |
| 2023 | 7 | 1 | G ▲ |
| 2024 | 7 | 0 | D |
| 2025 | 11 | 1 | G ▲ |
| 2026 | 5 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Ohio avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.67 | 3.45 | 3.95 | bottom 8% in Ohio; bottom 6% in the U.S. |
| Registered Nurse hours | 0.32 | 0.60 | 0.69 | bottom 6% in Ohio; bottom 11% in the U.S. |
| Weekend total nurse staffing | 2.43 | 3.07 | 3.50 | bottom 9% in Ohio; bottom 7% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.29 | 0.42 | 0.48 | bottom 28% in Ohio; bottom 31% in the U.S. |
| Total nursing staff turnover (%) | 68.8 | 48.7 | 45.8 | bottom 8% in Ohio; bottom 7% in the U.S. |
| RN turnover (%) | 70.0 | 43.9 | 42.9 | bottom 14% in Ohio; bottom 12% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.09, RN 0.37, weekend 2.80. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Kazarnovsky, Solomon | Individual | 5% or Greater Indirect Ownership Interest | 50% | 01/01/2023 |
| Lionstone HZ Opco Holdings LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/2023 |
| Stein, Abba | Individual | 5% or Greater Indirect Ownership Interest | 50% | 01/01/2023 |
| Cusner, Adam | Individual | Corporate Officer | NOT APPLICABLE | 01/27/2025 |
| Cusner, Adam | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/27/2025 |
| Cusner, Adam | Individual | ADP of the SNF | NOT APPLICABLE | 01/27/2025 |
| Degyansky, Jeffrey | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2020 |
| Degyansky, Jeffrey | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2023 |
| Degyansky, Jeffrey | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2023 |
| Goldish, Eliezer | Individual | Corporate Officer | NOT APPLICABLE | 10/09/2023 |
| Goldish, Eliezer | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/09/2023 |
| Goldish, Eliezer | Individual | ADP of the SNF | NOT APPLICABLE | 10/09/2023 |
| Kazarnovsky, Solomon | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2023 |
| Kazarnovsky, Solomon | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2023 |
| Kazarnovsky, Solomon | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2023 |
| Stein, Abba | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2023 |
| Stein, Abba | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2023 |
| Stein, Abba | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "Who on your staff manages IV therapy, and what training and monitoring is in place?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Ohio Living Swan Creek | 1.3 mi | Toledo, OH | ★★★☆☆ | 2/5 | |
| Foundation Park Care Center | 1.8 mi | Toledo, OH | ★★☆☆☆ | 1/5 | |
| Concord Care Center of Toledo | 1.9 mi | Toledo, OH | ★★☆☆☆ | 1/5 | |
| Lutheran Village at Wolfcreek | 2.2 mi | Holland, OH | ★★★★☆ | 3/5 | |
| Continuing Healthcare of Toledo | 2.5 mi | Toledo, OH | ★★☆☆☆ | 2/5 | |
| Ridgewood Manor | 2.5 mi | Maumee, OH | ★★★☆☆ | 3/5 | |
| Kingston Health Center of Perrysburg | 3.0 mi | Perrysburg, OH | ★★★★☆ | 4/5 | |
| Spring Meadows Nursing, a Villa Center | 3.3 mi | Holland, OH | ★★★☆☆ | 3/5 | |
| Addison Heights Health and Rehabilitation Center | 3.5 mi | Maumee, OH | ★★☆☆☆ | 1/5 | SFF |
| Advanced Healthcare Center | 3.6 mi | Toledo, OH | ★★★★☆ | 3/5 | |
| Lakes of Monclova Health Campus the | 3.7 mi | Maumee, OH | ★★★★★ | 4/5 | |
| Manor at Perrysburg | 4.0 mi | Perrysburg, OH | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 365737.