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Sienna Hills Nursing & Rehabilitation

73841 Pleasant Grove Road, Adena, OH 43901 · For profit - Corporation · 43 certified beds · (740) 546-3013 Medicare & Medicaid certified

Call the home — (740) 546-3013 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 2023Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2023
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS
Urgent care / clinic
211 U S Route 250 · (740) 546-3338 · Call to confirm hours
Pharmacy
74 Main St · (740) 769-2371 · Call to confirm hours
Grocery
72690 Colerain Rd · (740) 635-3770 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
73339 Pleasant Grove Rd · (740) 338-1065

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.8%5.3%15.4%typical for the state — see note marked double-dagger below the table
Long-stay residents who lose too much weight2.7%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms21.3%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.7%3.2%3.3%typical
Long-stay residents whose ability to walk worsened3.8%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication32.5%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers1.5%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control18.9%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.0%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine61.5%75.6%79.4%worse
Long-stay hospitalizations per 1,000 resident days1.501.731.67better
Long-stay outpatient ER visits per 1,000 resident days1.871.801.80typical

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

0.11U.S. median 0.31
Therapy hours / resident / day
0.02hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.11 therapist hours per resident per day in 2026Q1 — more than 7% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 55% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.61
RN hours/ resident / day
0.72
LPN hours/ resident / day
1.74
Aide hours/ resident / day
3.07
Total nurse hours/ resident / day
0.41
RN hoursweekends
44.8%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 43 beds and averages 38.1 residents a day — about 89% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.07 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.74 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.56 hrs/resident/day on weekends vs 3.28 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.70 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

9
deficiencies at the latest standard inspection (2025-02-06)
7
at the previous standard inspection (2022-12-01)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.

  • Actual harm · G2023-08-30 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, hospital record review, self-reported incident review, policy review and interview the facility failed to prevent an incident of resident-to-resident sexual abuse/assault involving Resident #13. Actual harm occurred based on the reasonable person concept on 08/22/23 when Resident #13, who was severely cognitively impaired and was unable to provide evidence of consent was sexually assaulted by Resident #26 who was observed fondling the resident's breast and with possible vaginal bleeding (per hospital record review). This affected one (Resident #13) of three residents reviewed for abuse. The facility census was 25. Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Resident #13 had diagnoses including early onset Alzheimer's disease, muscle contractures of the right hand and right and left elbows, oral phase dysphagia, insomnia, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-02 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of a service order, review of the facility's grievance/ concern log, review of resident council meeting minutes, resident interview, and staff interview, the facility failed to ensure residents were afforded the right to a comfortable living environment by not maintaining comfortable temperature levels in the facility's shower room while residents were bathing. This had the potential to affect all but three residents (#10, #27, and #33) of the facility's 33 residents, who the facility identified as not having the use of the shared shower room. Findings include: On 04/01/25 at 10:18 A.M., an observation of the facility's only shared shower room located on the 300 hall revealed it did not have a working heater. There was a long heater that was noted to run along the back wall of the shower room that was part of the heat supplied by the facility's boilers. There was no way to turn on the wall unit that was part of the boiler system from inside the shower room. There was another 12 inch…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-02 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a facility-reported incident, staff statements, and staff interview, the facility failed to ensure staff treated all residents with respect and dignity. This affected one resident (#10) of three residents reviewed for facility-reported incidents (FRI). The facility census was 33 . Findings include: Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage, cerebral infarction, and vascular dementia. Review of a minimum data set (MDS) dated [DATE] revealed Resident #10's cognition was severely impaired. Review of a witness statement by Certified Nursing Assistant (CNA) #300 dated 02/13/25 revealed Resident #10 had asked to go back to her room. CNA #300 and #215 took Resident #10 to her room and when they opened the door, CNA #110 was there and stated, I'm not putting her to f*cking bed, I put her to bed once already. CNA #300 stated this was said in front of Resident #10. CNA #300 & #215 laid Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-02-06 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure resident rooms and common areas were maintained in a clean and comfortable manner by repairing and painting walls properly. This had the potential to affect all 34 residents within the facility. Findings include: Observations throughout the survey from 02/03/25 to 02/06/25 revealed numerous resident rooms and common areas with evidence of repaired drywall which had not been properly painted. Observations with the facility administrator on 02/06/25 from 9:30 A.M. to 9:40 A.M. revealed the following areas of disrepair concerns: • room [ROOM NUMBER] had drywall repair without evidence of repainting • hallway next to room [ROOM NUMBER] had drywall repair without evidence of repainting • room [ROOM NUMBER] had drywall repair without evidence of repainting • room [ROOM NUMBER] had drywall repair without evidence of repainting • room [ROOM NUMBER] drywall repair without evidence of repainting • room [ROOM NUMBER] damaged drywall from resident beds…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, review of the Beneficiary Notice worksheet, review of the Notice of Medicare Non-Coverage (NOMNC) 10123 instructions, and record reviews, the facility failed to provide the Quality Improvement Organization (QIO) name and contact information. This affected four (Resident #1, Resident #11, Resident #33, Resident #34) of five residents reviewed for beneficiary notification. Findings included: 1. Record review revealed Resident #34 was admitted to the facility on [DATE] with a diagnoses including atrial fibrillation, dysphagia, muscle weakness, and cognitive communication deficit. Review of entrance conference worksheet for Beneficiary Notice (resident who has been discharged from Medicare covered Part A stay with benefits days remaining in the past six months) undated revealed Resident #34 was discharged from skilled services on 12/26/24 and had remained in the facility. Review of Notice of Medicare Non-Coverage (NOMNC) 10123 dated 12/24/24 revealed the QIO name and contact information was not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-06 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident personal items were safe guarded from potential theft. This affected one resident (Resident #15) of one residents reviewed for personal property. Findings included: Medical record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, type II diabetes, hypertension, dysphagia, major depressive disorder, end stage renal disease and dialysis dependent. Review of Resident #15's quarterly minimum data set (MDS) dated [DATE] revealed a brief interview of mental status score (BIMS) of 15 (out of 15), meaning cognition intact. Interview on 02/03/25 at 9:01 A.M. with Resident #15 revealed his personal snacks, located in his drawer, have come up missing. The resident believed Resident #6, who shared a [NAME] and [NAME] bathroom, comes in through the bathroom door and takes his snacks. The resident had reported the missing snacks several times to staff, however it…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-06 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) document accurately reflected an in-patient psychiatric hospitalization/significant change of condition. This affected one (Resident #37) of one residents reviewed for PASRR documents. The census was 34. Findings Include: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including schizophrenia, bipolar disorder, anxiety disorder, dementia, liver disease, multiple sclerosis, anxiety disorder, epilepsy, unspecified intellectual disabilities, and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/09/25, revealed the resident was cognitively intact. Review of a nursing progress note, dated 10/29/24, revealed Resident #5 was admitted for an inpatient psychiatric evaluation. Review of the psychiatric hospital's Discharge Summary revealed Resident #5 was admitted on [DATE] for increased…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-06 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews, observations, and policy review the facility failed to ensure Resident #195 was assessed for activity preferences and offered activities to meet his interests. This affected one (Resident #195) of one residents reviewed for activities. Findings included: Record review revealed Resident #195 was admitted to the facility on [DATE] with diagnoses including depression, cerebral infarction, diabetes type one, and difficulty walking. Review of Resident #195's medical record revealed no evidence of an activity assessment. Review of Resident #195's progress notes revealed on 01/24/25 a social services note was entered at 4:08 P.M., that indicated the resident was dependent for all care and administration of medications. The resident had hearing aids and glasses. His speech was clear, and he was easily understood. There was no evidence that the resident's activity preferences were reviewed. Review of Resident #195's task (Certified Nursing Assistants) documentation dated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interviews, and policy review, the facility failed to ensure an individualized, comprehensive plan of care was in place to ensure safe smoking strategies and skin alterations from smoking were timely identified. This affected one resident (Resident #6) of one residents reviewed for smoking. Findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including delusions, paranoid schizophrenia, depression, diabetes, dementia, behavioral disturbances, Alzheimer's, glaucoma, nicotine dependence (cigarettes), and abnormal involuntary movements. Review of Resident #6 smoking assessment dated [DATE] and 01/03/25 revealed the resident had no cognitive loss or dexterity problems. The resident had a visual deficit. The resident smokes five-10 times a day and used a smoking apron and required supervision. The facility stored the lighter and cigarettes. The plan of care was to assure residents were safe while smoking. There…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of dialysis dietician notes, and medical record review, the facility failed to provide Resident #15 with appropriate diet and snacks as ordered by the dialysis center dietician and failed to ensure communication between the facility dietician and dialysis dietician occurred to provide Resident #15 a comprehensive nutrition plan to meet the resident's needs. This affected one resident (Resident #15) of one reviewed for dialysis. Findings included: Review of Resident #15's medical record revealed an admission date of 09/14/24 with diagnoses including type 2 diabetes, morbid obesity, heart failure, sepsis, hypertension, and end stage renal disease- dialysis dependent. Further review revealed no evidence of dialysis dietician communication notes since 04/23/24. Review of the nutritional communication forms/notes from dialysis dated 10/28/24, 12/18/24 and 01/27/25 (with a faxed date of 02/04/25 on the forms) revealed the dialysis dietician ordered a high protein snack at night,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-06 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of dialysis communication notes, and record review the facility failed to ensure Resident #15 received medication as ordered and the dialysis plan of care was accurate. This affected one (Resident #15) of one reviewed for dialysis. Findings included: Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, type 2 diabetes, morbid obesity, pneumonia, heart failure, sepsis, hypertension, dysphagia, bundle branch block, major depressive disorder, end stage renal disease dialysis dependent. a. Review of the nutritional communication form from dialysis dated 10/28/24, 12/18/24, and 01/27/25 revealed Resident # 15 did not meet his phosphorous goal of 3.0-3.5. Orders to administer calcium acetate at each meal and snack. Review of un-dated mealtimes (provided by the facility) revealed breakfast was at 7:45 A.M., lunch at 12:00 P.M., and dinner at 5:15 P.M. Review of Resident #15's orders and Medication…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · D2025-02-06 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and policy review, the facility failed to ensure appropriate infection control practice were implemented when an indwelling urinary catheter drainage bag was in contact with the floor. This affected one (Resident #185) of one resident reviewed for indwelling urinary catheters. There were no additional residents with urinary catheters residing in the facility. The facility census was 43. Findings include: Review of the medical record revealed Resident #185 was admitted to the facility on [DATE] with diagnoses including obstructive reflex uropathy, acute kidney failure, diabetes mellitus, coronary artery disease, morbid obesity, bipolar disorder, and Fournier gangrene (serious, sometimes fatal, bacterial infection of the external genitalia or scrotum.) Review of the admission Minimum Data Set (MDS) assessment, dated 02/01/25, revealed Resident #5 was cognitively intact. There were no behaviors or rejection of care. The resident required physical assistance from staff for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-18 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of self-reported incident report (SRI) tracking number 239957, and interview, the facility failed to ensure a comprehensive, resident-centered care plan related to resident behaviors was maintained. This affected one (Resident #1) of three residents reviewed for abuse. The facility census was 29. Findings include: Review of the medical record for Resident #1 revealed an admission date of 08/05/22. Diagnoses included Down syndrome, morbid obesity, urethral stricture, and impulse disorder. Review of Resident #1's plan of care, dated 08/23/22, revealed the resident received psychotropic medication related to behaviors of agitation and combativeness (flailing arms during personal care and hitting himself during personal care) due to impulse control problems. Interventions included administering medication as ordered and monitoring for target behaviors: agitation, aggression, combativeness, verbal outbursts, and throwing food and drinks onto floor. Review of the annual Minimum Data Set (MDS) assessment, dated 07/21/23, revealed the resident had moderately…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-12-01 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, facility record review and facility policy review the facility failed to ensure food was stored and prepared under sanitary conditions. This had the potential to affect all Residents living in the facility and receiving meals from the kitchen. The were no Residents identified by the facility as receiving nothing by mouth. The facility census was 34. Findings included: 1. Observation on 11/28/22 at 8:40 A.M. of meat in a plastic bag floating in water in the staff hand washing sink. The water was not running in the sink and the sink was plugged to make a pool of water. On 11/28/22 at 9:00 A.M. an interview with Dietary #213 verified the meat should not be thawed in a pool of water or in the staff hand washing sink. She reported the staff the evening before forgot to defrost the meat in the fridge and she was trying to thaw it quickly. Review of the facility policy titled, Food Handling Guidelines, undated, revealed thawing of frozen meat should be done in the following manners: under refrigeration at temperature below 41 degrees Fahrenheit, under…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-12-01 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview and facility policy review, the facility failed to ensure an outdoor dumpster lid was completely covering the opening to the dumpster to protect from pest infestation. This had the potential to affect all 34 Residents living in the facility. The facility census was 34. Findings included: Observation on 11/28/22 at 08:30 A.M. of the outdoor dumpster revealed one fourth of the lid was missing leaving the refuse open to air and pests. Observation on 11/29/22 at 12:30 P.M. of the outdoor dumpster revealed one fourth of the lid was missing leaving the refuse open to air and pests. On 11/29/22 an interview with Dining Services Director (DSD) #204 revealed the trash dumpster had been missing part of the lid for a few weeks and the facility probably should have notified the trash company of the broken lid. Review of the facility policy titled, Solid Waste Disposal, undated, revealed garbage containers would be covered at all times.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-12-01 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview the facility failed to ensure a kitchen oven was maintained in safe operating condition. This had the potential to affect all 34 Residents living in the facility. The facility census was 34. Findings included: Observation on 11/28/22 at 8:40 A.M. of the left kitchen oven revealed the door of the oven had a piece of wood wedged into the top of it. An interview at the time of the observation with Dietary #213 revealed the oven door did not close properly so the piece of wood was used to wedge the oven door closed. On 11/29/22 at 10:00 A.M. an interview with Dining Services Director (DSD) #204 revealed the spring in the left oven door was not working correctly and a company came to fix it but ended up making it worse and the door would not close all the way. DSD #204 verified the broke oven door and revealed the facility had been using the piece of wood to wedge the oven door closed for over a week. DSD #204 verified using the piece of wood on a hot oven was not safe operating condition.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-01 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to ensure Resident #12 had a physician order for a physical restraint called a Merry Walker. This affected one Resident (#12) of one Resident (#12) reviewed for physical restraints. The facility census was 34. Findings included: Review of Resident #12's medical record revealed she was initially admitted to the facility on [DATE] with the diagnoses of mild intellectual disabilities, hyperthyroidism, bipolar, and unspecified dementia. Review of Resident #12's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was minimally cognitively impaired, walked in the room, walked in the corridor, and had locomotion off the unit with supervision and no setup or physical help from staff. Her locomotion on unit required supervision and setup help only. Review of Resident #12's physician orders revealed no order for a Merry [NAME] ( an adaptive device combining a chair and walker which has four wheels and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-01 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to provide Resident #25 with activities to meet their preferences and interests. This affected one Resident (#25) of one Resident reviewed for activities. The facility census was 34. Findings include: Review of Resident #25's medical record revealed an admission date of 08/23/19 with diagnoses including dementia, anxiety and depression. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a severely impaired cognition level. Further review of the MDS assessment indicated Resident #25's activity interests included independent activities such as television and music. Review of the Annual Activity assessment, completed on 05/16/22, indicated Resident #25 preferred independent activities such as 1:1 visits. The assessment further identified Resident #25's favorite activities included television, people watching and sitting in the dining room observing other residents and activities. Review of the activity participation…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review the facility failed to ensure staff used appropriate hand hygiene when providing incontinence care. This affected one Resident (#24) of one Resident reviewed for bladder and bowel incontinence. The facility census was 34. Findings included: Review of Resident #24's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease with early onset, essential hypertension, weakness, and hypothyroidism. Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood and was severely impaired with cognitive skills for daily decision making. Review of the Activity for Daily Living (ADL) assistance section revealed she was totally dependent on two plus persons for physical assistance. The MDS also revealed Resident #24 was always incontinent of bladder and bowel. Observation on 11/30/22 at 10:19 A.M. of incontinence care for Resident #24…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to ensure oxygen was administered at the correct flow rate. This affected one Resident (#31) of one Resident reviewed for respiratory care. The facility census was 34. Findings included: Review of Resident #31's medical record revealed he was admitted to the facility on [DATE] with diagnoses including essential hypertension, hyperlipidemia, and chronic obstructive pulmonary disease (COPD). Review of Resident #31's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 was cognitively independent and did not receive oxygen. Review of Resident #31's physician order dated 11/25/22 revealed an order to administer oxygen at two liters per minute via a nasal cannula continuously to keep oxygen saturation above 92%. Review of Resident #31's oxygen saturations revealed saturations ranging from 92% to 98%. Review of Resident #31's care plan dated 11/17/22 revealed he was at risk for altered…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2020-03-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and policy review, the facility failed to ensure the kitchen was maintained in a clean, safe and sanitary condition. This had the potential to affect 36 of 37 residents. The facility identified one resident, Resident #26, as receiving nothing by mouth. Findings include: 1. On 03/02/20 at 10:50 A.M. the dishwasher repair man was observed in the dish room working on the dish washer and was not wearing a hair net. The stove/oven were located to the repairmen's right side and he had to walk past the food preparation areas/steam table to provide his service. This was verified with Dietary Director #13 at the time of the observation. Review of the facility Hair Net Policy, dated 05/19 revealed hair restraints shall be worn by all dietary employees while on duty to cover ALL hair and by anyone in the food preparation area. 2. On 03/02/20 at 10:55 A.M. observation of the reach in cooler revealed the following: • Two vanilla Dannon Creamy Yogurt and two strawberry Dannon Creamy Yogurt all dated 12/13/19; • Five vanilla Dannon Creamy Yogurt and four strawberry…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2020-03-05 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to ensure the facility was maintained in a clean, sanitary and homelike environment. This affected four residents (Resident #4, #12, #20, #29) of 37 residents residing in the facility. The census was 37. Findings include: 1. On 03/03/20 at 7:43 A.M. Resident #4's wheelchair armrests were observed to be cracked and torn on both arms. An additional observation on 03/04/20 at 4:00 P.M. revealed the arm rests remained cracked and torn with the left armrest missing approximately two inches of padding and the cracks remaining on both arm rests. 2. On 03/02/20 at 11:01 A.M. observation of Resident #29's room revealed brown splatter on the wall above the head board of her bed, and the privacy curtain hanging between her bed and her roommate's had multiple brown spots on the curtain. 3. On 03/02/20 at 2:30 P.M. observation of the sofas in the sitting room on 100 hall revealed the vinyl sofa facing the television to have approximately a twelve inch by six inch group of small cracks on the left sofa cushion, and the arms of the sofa were…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-03-05 · tag F0585 — failed to handle grievances — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, missing item log, policy review and interview, the facility failed to ensure staff were actively looking for missing items and that missing items were documented when reported. This affected one (Resident #2) of two residents reviewed for missing property. Findings include: Medical record review revealed Resident #2 was admitted on [DATE] with diagnosis including schizoaffective disorder. Review of the medical record and the Concern/Missing Item Log dated January 2020 through March 2020 revealed no evidence Resident #2 had any missing personal property. On 03/02/20 at 2:08 P.M., interview with Resident #2 stated he was missing one country compact disc (CD) and one gospel CD since the first part of February 2020. Resident #2 stated he had told Social Service (SS) #7, and the facility did not look for the items or replace them. On 03/04/20 at 9:19 A.M., interview with SS #7 verified Resident #2 had told her the CD's were missing and stated the CD's were not on his inventory list so…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-03-05 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure comprehensive assessments were accurate. This affected two (Residents #2 and #12) of four residents reviewed for preadmission screening and resident review. The census was 37. Findings include: 1. Medical record review revealed Resident #2 was admitted on [DATE] with diagnoses including schizoaffective disorder and anxiety disorder. On 01/04/19, Resident #2 was diagnosed with severe mania without psychotic symptoms. Review of the discharge return anticipated Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the cognition section of the comprehensive assessment was documented as 'not assessed'. On 03/04/20 at 10:50 A.M., interview with Assistant Director of Nursing (ADON) #4 verified the cognition section of Resident #2's above MDS assessment should have been completed. ADON #4 stated Social Service (SS) #7 did not complete the section due to the resident was not at the facility, and SS #7 did not realize there was a second part…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-03-05 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Residents #1, #12 and #20, who had indicators of serious mental illness and/or developmental disability, had a pre-admission screening and resident review (PASARR) completed to determine whether the resident qualified for Level II services. This affected three residents reviewed for PASARR. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 10/20/10 with diagnoses including adjustment disorder with mixed anxiety, depressed mood and anxiety disorder. Further review of the diagnosis list revealed paranoid schizophrenia was added to the resident's list on 08/14/18 when seen by Psychiatrist #99. Review of the five day/significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and was not currently considered by the state level 2 PASARR process to have a serious mental illness and/or intellectual disability or related condition. Review of the PASARR results…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-03-05 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, preadmission screening and resident review (PASARR) and interview, the facility failed to complete PASARR's as required. This affected two (Resident #12 and #26) of four residents reviewed for PASARR. The census was 37. Findings include: 1. Review of the Preadmission Screen (PAS) dated 01/31/12 revealed PAS Determination included to consult with the local county department of human services for facility payment. The resident was transferring to the facility on [DATE]. Review of the record revealed Resident #12 was admitted on [DATE] with diagnoses including intellectual disability, cerebral palsy, paranoid schizophrenia and anxiety. Review of the the History and Physical Examination dated 02/02/12 revealed the resident had a diagnosis of intellectual disability and bipolar disorder. Review of the record revealed no evidence an admission PASARR was completed, and the resident had a qualifying intellectual disability diagnoses. On 03/04/20 at 9:07 A.M., observation…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-03-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, resident and staff interview, the facility failed to ensure a resident was afforded the opportunity to participate in her own care plan conference. This affected one (Resident #8) of one resident reviewed for care plan conferences. Findings include: A review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia with behaviors, major depressive disorder, anxiety disorder, delusional disorder, Alzheimer's disease with early onset, osteoarthritis, atrial fibrillation, adult onset diabetes mellitus, hypertension, chronic obstructive pulmonary disease and atherosclerotic heart disease. A review of Resident #8's profile in her electronic health record revealed she had a court appointed guardian. The guardianship went into effect on 11/01/13, and the resident was deemed to be incompetent. A review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had adequate…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-03-05 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, preadmission screening and resident review (PASARR) and interview, the facility failed to ensure discharge planning was on-going to meet the needs of the resident. This affected one (Resident #2) of four residents reviewed for PASARR. The census was 37. Findings include: Medical record review revealed Resident #2 was admitted on [DATE] with diagnoses including schizoaffective disorder and anxiety. Review of the care plan: Discharge planning, dated 04/13/18, revealed the resident's placement at the facility was long term, and the goal was to continue to adjust and accept facility placement. On 11/25/19, an assessment was completed by the Area of Aging for an Assisted Living Waiver for Resident #2. Review of the Multidisciplinary Care Conferences dated 11/27/19 revealed the resident was to be discharged to the community. Passport had completed their assessment and recommendations were to be sent to the facility and Home Choice had appointed a transition coordinator. Further review…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-03-05 · tag F0675 — failed to support quality of life — isolated
    Honor each resident's preferences, choices, values and beliefs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, personal fund review, social security administration payee request review and interview, the facility failed to consistently pursue the whereabouts of a resident's social security payee status. This affected one (Resident #6) of three residents reviewed for personal funds. Findings include: Medical record review revealed Resident #6 was admitted on [DATE] with diagnosis of early onset of Alzheimer's disease. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 entered the facility from the community and had impaired cognition for daily decision-making. Review of the Social Security Administration: Payee Request dated 09/05/19 revealed the facility requested payee for resident social security, and the resident owed the facility the patient's monthly liability. There was no confirmation the request dated 09/05/19 was sent or received by Social Security Administration. There was also no evidence of subsequent attempts to receive the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-03-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, the facility failed to ensure specialized equipment met the positioning needs of a resident. This affected one (Resident #12) of two residents reviewed for positioning. The census was 37. Findings include: Medical record review revealed Resident #12 was admitted on [DATE] with diagnoses including cerebral palsy and intellectual developmental disorder. Review of the care plan: Potential for Self-care Deficit, revised 07/13/17, revealed therapy was to treat and evaluate as needed and staff was to notify therapy of any decline in condition. Review of the monthly Order Summary Report dated 03/05/20 revealed Resident #12 was ordered a tilt and space (specialty) wheelchair with Dycem (non-slip material) and pressure reduction cushion as tolerated. On 03/04/20 at 9:07 A.M., Resident #12 was observed in the dining room in a specialized wheelchair leaning to right with no bolsters, positioning devices or supports to maintain an upright position. A communication…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-03-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's nursing drug handbook and staff interview, the facility failed to ensure hypnotic (medications that induce sleep) medications were not used longer than their intended use, without a gradual dose reduction attempt, and without adequate monitoring of the resident's target behavior. This affected one (Resident #28) of five residents reviewed for unnecessary medications. Findings include: A review of Resident #28's medical record revealed she was admitted to the facility from another nursing facility on 01/30/20. She was [AGE] years old and had the diagnoses of insomnia, dementia without behavioral disturbances and major depressive disorder. A review of Resident #28's active physician's orders revealed she was receiving Restoril (a hypnotic/ benzodiazepine used for the treatment of insomnia) 7.5 milligrams (mg) by mouth (po) every night at bedtime for insomnia. The order had been in place since her admission on [DATE] but originated on 07/03/19, while she was residing…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to HILLSTONE HEALTHCARE — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.9-0.9 vs chain
Health inspection 3 of 53.3-0.3 vs chain
Staffing 1 of 51.8-0.8 vs chain
Quality measures 5 of 55.0≈ chain avg
The other 8 homes this chain runs (chain average 3.9★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
BUNNER, MICHAELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER5%since 05/22/2012
MALLETT, CHRISTOPHERIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER25%since 01/01/2013
PARSONS, BENJAMINIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER20%since 01/01/2013
SPRENGER, MARKIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER25%since 01/01/2014
SPRENGER, TIMOTHYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER25%since 01/01/2013
BERGSTEN, PAULIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2022
DAPORE, MATTHEWIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2022

CMS files one row per role, so the 20 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$2.6M
Net patient revenuemost recent cost report
-7.0%
Operating marginrevenue minus expenses
$239K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 5%Other / private 36%

This home reported $239K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$221per resident / day
operating cost
$6,726per month
≈ monthly operating cost
$207per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.

Typical monthly cost in Ohio
$9,186/mo
Nursing home (semi-private)
$10,389/mo
Nursing home (private)
$6,103/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365922. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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