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Hickory Ridge Nursing & Rehabilitation Center

721 Hickory St, Akron, OH 44303 · For profit - Corporation · 155 certified beds · (330) 762-6486 Medicare & Medicaid certified

Call the home — (330) 762-6486 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0610) — most recent Jan 2026Behavioral-health or dementia-care citation — no harm found (F0740)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

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 citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (23) — 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
★★★★★ 5/5 CMS
Urgent care / clinic
400 W Market St · (833) 427-5634 · Call to confirm hours
Pharmacy
786 W Market St · (330) 535-3153 · Call to confirm hours
Grocery
9 E Tallmadge Ave · (330) 849-5135 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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 fell from 4 to 3 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 rating3★
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 increased1.5%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight3.9%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.1%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.2%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms89.5%30.1%6.5%worse 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 injury0.9%3.2%3.3%better
Long-stay residents whose ability to walk worsened1.9%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication21.1%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine82.6%94.5%95.3%worse
Long-stay residents with pressure ulcers1.3%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 table20.7%8.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.5%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine45.2%75.6%79.4%worse

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
0.07hours / resident / day
Physical therapy
0.02hours / resident / day
Occupational therapy
0.02hours / 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 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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

0.31
RN hours/ resident / day
1.06
LPN hours/ resident / day
1.83
Aide hours/ resident / day
3.20
Total nurse hours/ resident / day
0.21
RN hoursweekends
40.6%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 155 beds and averages 140.3 residents a day — about 91% occupied, or roughly 15 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 3.20 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.99 hrs/resident/day on weekends vs 3.28 on weekdays — 9% thinner on weekends. RN hours go from 0.35 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

12
deficiencies at the latest standard inspection (2026-01-14)
1
at the previous standard inspection (2023-01-12)

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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Fcited before2026-01-14 · 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 observations, interviews and facility policy review, the facility failed to ensure clean food service areas. This had the potential to affect all residents who received meals from the kitchen. The facility did not identify any residents who received nothing by mouth. The facility census was 141.Findings include:Observation of the kitchen area on 01/05/26 between 8:14 A.M. and 8:35 A.M. with Dietary Manager (DM) #378 revealed the following that was verified at the time of discovery:- There were mold and dried liquid droplets on four out of four racks in reach-in #1.- There were mold and dried liquid droplets on five out of six racks in reach-in #1.- The shelf underneath the steam table had food residue, food crumbs and pieces of parchment paper.- The back splash of the mixer had dried batter on it.- In the dish area, the final rinse of the dish machine registered 169 degrees Fahrenheit (F). Dietary Aide (DA) #447 put a rack of plate lids that were not stacked appropriately to be washed on top of a rack of plastic bowls. DM #378 stated that racks should not be put on top of…

    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 · E2026-01-14 · tag F0807 — failed to offer suitable drinks — pattern
    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
    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, interview and facility policy review, the facility failed to honor preferences. This affected six residents (#9, #17, #71, #105, #106, and #129) out of six residents for beverage preferences. This had the potential to affect 141 residents who received meals from the facility. No residents were identified as receiving nothing by mouth (NPO). The facility census was 141.Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 12/19/25. Diagnoses included fracture of the upper end of right tibia, muscle weakness, and osteoarthritis.Review of the care plan dated 11/20/25 for Resident #17 revealed there was a potential for alteration in nutrition due to diagnoses. Interventions included but not limited to providing diet as ordered and honoring preferences.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had intact cognition and required supervision for eating and partial assistance for other…

    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 before2026-01-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility policy review, the facility failed to ensure staff utilized appropriate hand hygiene during medication administration. This affected four residents (#27, #68, #105, and #116) out of eight residents observed for medication administration. The facility census was 141.Findings include:Observation on 01/08/26 from 8:23 A.M. to 8:39 A.M. of medication administration with Licensed Practical Nurse (LPN) #388 revealed the following: on 8:23 A.M. LPN #388 dispensed and administered medications to Resident #19 and did not complete hand hygiene after; LPN #388 then immediately dispensed and administered medications to Resident #27 and did not complete hand hygiene after; and then LPN #388 immediately dispensed and administered medication to Resident #105.An interview on 01/08/26 at 8:43 A.M. with LPN #388 verified the above findings. Observation on 01/08/26 from 8:45 A.M. to 9:11 A.M. of medication administration with LPN #435 revealed the following: LPN #435 dispensed and administered medications to Resident #137 and did not complete hand hygiene…

    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 · D2026-01-14 · 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 medical record reviews, observations, interviews, personnel file review, and employee handbook review, the facility failed to ensure resident respect and dignity was maintained when Certified Nursing Assistants (CNA) acted in an unprofessional manner while working in the facility. This affected two residents (Resident #01 and #85) out of eight residents reviewed for abuse. The facility census was 141.Findings include:Review of the medical record for Resident #85 revealed admission date of 08/25/22 with diagnoses including, but not limited to, unspecified dementia, alcohol dependence with alcohol-induced dementia, vascular dementia, anxiety, depression, insomnia, encephalopathy, and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 had a Brief Interview Mental Status (BIMS) score of 09 indicating impaired cognition. The assessment indicated he could adequately hear, had clear speech, understood others, and had no behaviors noted. Review of…

    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 · D2026-01-14 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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, medical record review, personnel file review, and policy review, the facility failed to implement their abuse protocol when an allegation of verbal abuse was reported to staff. This affected one resident (Resident #80) of seven residents reviewed for abuse. The facility census was 141. Findings Include: Resident #80 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, high blood pressure, atrial fibrillation, dementia without behavioral disturbance, anxiety disorder, high risk heterosexual behavior, major depressive disorder, and liver cell carcinoma. Review of the comprehensive Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #80 was cognitively intact and exhibited no behaviors. Review of the nursing notes revealed an Interdisciplinary Team (IDT) note dated 12/19/25 at 12:28 P.M. revealed Licensed Practical Nurse (LPN) #505 reviewed Resident #80's behaviors in the last 90 days included cursing at others, destructive…

    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 · D2026-01-14 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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, observations, interviews, and facility policy reviews, the facility failed to ensure a thorough investigation was completed for verbal abuse during a self-reported incident (SRI) investigation. This affected one (Resident #85) out of eight residents reviewed for abuse. The facility census was 141.Findings Include:Review of the medical record for Resident #85 revealed an admission date on 08/25/22 with diagnoses including, but not limited to, unspecified dementia, alcohol dependence with alcohol-induced dementia, vascular dementia, anxiety, depression, insomnia, encephalopathy, and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 had a Brief Interview Mental Status (BIMS) score of 09 indicating impaired cognition.Review of SRI #269286 from the facility on 01/01/26 revealed Certified Nursing Assistant (CNA) #413 made inappropriate comments to Resident #85. The staff member was suspended but had no previous…

    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 before2026-01-14 · 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 observation, interview, and record review the facility failed to ensure safe smoking interventions were in place for Resident #106 and failed to ensure fall interventions were implemented at all times for Resident #16 and Resident #25. This affected three residents (Resident #16, Resident #25, and Resident #106) out of eight residents reviewed for accidents. The facility census was 141.1.Review of the medical record for Resident #106 revealed an admission date of 05/17/17. Diagnoses included but not limited to chronic atrial fibrillation, chronic obstructive pulmonary disease and nicotine dependence. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #106 had intact cognition and required supervision for activities of daily living. Review of the physician's orders for January 2026 revealed that Resident #106 was ordered to wear a fire-retardant apron when smoking for safety. Review of the care plan dated 08/26/21 with a revision date of 9/21/22 for 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-14 · 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, and record review, the facility failed to ensure proper diets were followed. This affected three residents (Residents #17, #71, and #106) out of five residents for nutrition. The facility census was 141.1. Review of the medical record for Resident #17 revealed an admission date of 12/19/25. Diagnoses included but not limited to fracture of the upper end of right tibia, muscle weakness, and osteoarthritis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had intact cognition and required supervision for eating and partial assistance for other activities of daily living. Review of the physician's orders for January 2026 revealed that Resident #17 was ordered a regular diet with regular texture and thin liquids diet with double entrees all meals, eggs grits and meat related to at risk for malnutrition. Review of the care plan dated 11/20/25 for Resident #17 revealed there was a potential for alteration in nutrition due to diagnoses.…

    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 · D2026-01-14 · 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

    Based on record review, observations and interviews, the facility failed to ensure respiratory equipment was maintained in a sanitary manner and oxygen orders were individualized to meet resident specific needs to reduce the risk of complications from variations in oxygen treatment. This affected two (Residents #127 and #136) of two residents reviewed for respiratory care with the potential to affect 20 residents who utilized oxygen. The facility census was 141.Findings include:1. Review of the medical record for Resident #127 revealed an admission date of 09/25/23 with diagnoses including dementia, chronic obstructive pulmonary disease (COPD) and protein-calorie malnutrition.Review of the care plan dated 09/28/23 for Resident #127 revealed she had respiratory deficiencies or abnormalities of pulmonary function related to COPD, allergic rhinitis and emphysema. She also had shortness of breath on exertion. Interventions included for staff to monitor lung sounds as ordered, monitor oxygen saturation as ordered, administer oxygen as ordered, respiratory assessments as ordered and to…

    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 · D2026-01-14 · 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 staff interviews, medical record review, and facility policy review, the facility failed to ensure a resident who required dialysis received ongoing assessments of condition before and after dialysis treatments. This affected one Resident (#14) of one resident identified as receiving dialysis. The facility census was 141.Review of the medical record for Resident #14 revealed an admission date of 06/19/19 and diagnoses including end stage renal disease (ESRD), diabetes mellitus, dependence on renal dialysis, morbid obesity, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF).Review of the plan of care dated 05/13/20 revealed Resident #14 received dialysis treatments three times per week for ESRD. It was noted Resident #14 frequently refused to go to dialysis treatments. Interventions included assist with transfer needs when going to dialysis, auscultate lung sounds as ordered, monitor for edema, check for new orders upon return from dialysis, send lunch with resident to…

    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 13 citations
  • Potential for harm · D2026-01-14 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and 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, and record review the facility failed to ensure behavioral health interventions were implemented for Resident #45 with PICA (a mental health condition where a person eats things that aren't food). This affected one resident (Resident #45) out of three residents reviewed for behaviors. The facility census was 141. Findings include: Review of the medical record for Resident #45 revealed they were admitted to the facility on [DATE] with diagnoses that included diabetes mellitus type two, dementia with behavioral disturbance, hearing loss, anxiety disorder, peripheral vascular disease, and chronic kidney disease. Review of the physician orders from 12/01/25 to 01/07/26 revealed the absence of any orders to monitor Resident #45 for gastrointestinal (GI) symptoms related to PICA or to monitor Resident #45's physical environment for broken or damaged items that could be ingested. Review of the progress notes revealed the following: on 11/21/25 Resident #45 was documented as having…

    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 · Dcited before2026-01-14 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    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 Resident #135's medical record was complete and accurate to reflect secured unit placement. This affected one resident (Resident #135) of three residents reviewed for medical records related to behavioral health services.Findings include:Review of the medical record for Resident #135 revealed they were admitted to the facility on [DATE] with diagnoses that included epilepsy, bipolar disorder, suicidal ideation, impulsiveness, anxiety, and need for assistance with personal care. Review of the current physician orders revealed the absence of an order for Resident #135 to reside in a secured unit. On 12/03/24 the order for placement on a secured unit was discontinued.Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #135 was cognitively intact, exhibited delusions, exhibited verbal behaviors, and required supervision or touching assistance for activities of daily living. An interview on 01/13/26 at 10:12 A.M. with LPN #382…

    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 · Ecited before2025-01-28 · tag F0880 — failed to prevent and control infections — pattern
    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, record review, interview, policy and procedure review, and review of the Centers for Disease Control (CDC) guidance, the facility failed to ensure staff performed appropriate hand hygiene and ensure all staff implemented enhanced barrier precautions. This affected two of three residents reviewed for incontinence care (Residents #65 and #8) and one of 20 residents who ate their meals and resided on the 100 hall (Resident #58). These failures also had the potential to affect all 20 residents currently residing on the 100 hall (Residents #8 #17, #25, #37, #58, #65, #71, #74, #75, #78, #94, #95, #105, #109, #117, #135, #137, #139, #143 and #146). The facility census was 147. Findings include: 1. Clinical record review revealed Resident #65 was admitted on [DATE] with diagnoses including liver cancer, chronic bronchitis, aphasia, high blood pressure, heart failure, intermittent explosive disorder, dementia, anxiety, viral hepatitis, hyperlipidemia, ventral hernia, and intestinal obstruction.…

    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 · D2025-01-28 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 staff interview the facility failed to ensure Resident #65's care plan clearly reflected interventions to be used for safe transfer. This affected one (#65) out of three residents reviewed for falls. The facility census was 147. Findings include: Clinical record review revealed Resident #65 was admitted on [DATE] with diagnoses including liver cancer, chronic bronchitis, aphasia, high blood pressure, heart failure, intermittent explosive disorder, dementia, anxiety, viral hepatitis, hyperlipidemia, ventral hernia, and intestinal obstruction. Review of Resident #65's plan of care initiated on 08/15/24 indicated Resident #65 was at risk for falls related to a diagnosis of impaired cognition, dementia, anxiety, pain, use of psychotropic medications, and medical conditions including unsteadiness on feet, abnormalities of gait and mobility, abnormal posture, dizziness and giddiness. Interventions on the plan of care included to ensure environment was free of clutter and maintain a clear…

    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 before2025-01-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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, interview, and review of the nursing assistant job description, the facility failed to ensure Resident #17 was consistently assisted with shaving his facial hair on a daily basis. This affected one (#17) out of three residents reviewed who were dependent of staff for assistance with their activity of daily living (ADL) needs. The facility census was 147. Findings include: Clinical record review revealed Resident #17 was admitted on [DATE] with diagnoses including multiple sclerosis, cerebral infarction (stroke), depression, transient ischemic attack (TIA), heart failure and dementia. Review of Resident #17's Minimum Data Set (MDS) assessment dated [DATE] indicated he had mild cognitive impairment. Review of Resident #17's plan of care initiated on 11/08/24 revealed Resident #17 could require assistance with ADLs and could be at risk of developing complications associated with decreased ADL self-performance. Fluctuations and/or decline expected due to progressive neurological…

    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 · Dcited before2025-01-28 · 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 record review, resident and staff interviews, and policy and procedure review, the facility failed to ensure the safe transfer of Resident #65 resulting in a fall and failed to maintain Resident #137's care planned interventions to prevent falls. This affected two (#65 and #137) of three residents reviewed for falls. The facility census was 147. Findings include: 1. Clinical record review revealed Resident #65 was admitted on [DATE] with diagnoses including liver cancer, chronic bronchitis, aphasia, high blood pressure, heart failure, intermittent explosive disorder, dementia, anxiety, viral hepatitis, hyperlipidemia, ventral hernia, and intestinal obstruction. Review of Resident #65's plan of care initiated on 08/15/24 indicated Resident #65 was at risk for falls related to a diagnosis of impaired cognition, dementia, anxiety, pain, use of psychotropic medications, and medical conditions including unsteadiness on feet, abnormalities of gait and mobility, abnormal posture, dizziness and giddiness.…

    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 · Dcited before2025-01-28 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    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, interview, and review of the American Nurses Association (ANA) guidelines for accuracy of documentation, the facility failed to ensure staff accurately documented the presence of interventions to prevent a fall. This affected one of three residents reviewed for falls (Resident #137). The facility census was 147. Findings include: Clinical record review revealed Resident #137 was admitted on [DATE] with diagnoses including diabetes mellitus, pulmonary disease, cerebral vascular disease, heart failure with a cardiac defibrillator implanted device, high blood pressure, atherosclerotic disease, peripheral vascular disease, cataracts with visual disturbances, thrombocytopenia, carpal tunnel syndrome of upper limbs, osteoarthritis, and breast cancer. Resident #137 had medical conditions including low back pain, unsteadiness on feet, muscle weakness, and abnormal gait, mobility and need for assistance with personal care. Review of Resident #137's plan of care initiated 12/05/2023 indicated a…

    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 before2024-06-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, and interview the facility failed to provide oral care in a timely manner. This affected one (Resident #1) of three residents reviewed for activities of daily living. The census was 139. Findings include: Review of the medical record for Resident #1 revealed an admission date of 11/13/20. Diagnoses included schizoaffective disorder, type two diabetes, morbid obesity, unspecified dementia. Resident #1 required assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/26/24, revealed Resident #1 had intact cognition and was dependent for bed mobility, transfers, and oral care. Review of the Plan of care dated 01/19/20 revealed Resident #1 had impaired dentition and was at risk for oral problems related to broken, loose teeth with interventions including to provide oral care at least daily and/or more frequently as needed. Review of the oral care task sheet for Resident #1 dated 05/20/24 through 06/17/24 revealed on 05/22/24, 05/24/24, 05/25/24, 05/26/24, 05/27/24, 05/30/24, 06/03/24, 06/03/24,…

    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 · F2023-01-12 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews with residents, interview with dietary staff, review of a test tray, and review of the facility policy the facility failed to ensure foods were palatable and served at appropriate temperatures. This had the potential to affect 127 residents who received food from the kitchen. The facility identified one resident (#117) as receiving nothing by mouth. The facility census was 128. Findings include: On 01/09/23 at 10:35 A.M., interview with Resident #87 stated the food did not taste good. On 01/09/23 at 10:43 A.M., interview with Resident #77 stated the food was cold and did not taste good. On 01/09/23 at 10:50 A.M., interview with Resident #63 stated the food was cold. On 01/11/23 from 12:36 P.M. to 12:51 P.M., review of a test tray with Certified Dietary Manager (CDM) #700 revealed the meal included meatloaf, mashed potatoes, and corn. The test tray was started on the tray line at 12:36 P.M., had a hot plate warmer under the plate, was covered with a dome lid, loaded onto a closed cart at 12:37 P.M., the cart was delivered to the 400-hall at 12:38 P.M., and 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2020-01-15 · 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 floor, storage areas and equipment was maintained in a clean manner, foods were properly stored in the refrigerator and freezer, and foods were served to the residents in a sanitary manner. This had the potential to affect all 146 residents currently residing in the facility who received food prepared in the kitchen. Findings include: 1. Initial tour of the kitchen on 01/12/20 at 9:00 A.M. revealed papers, multiple food crumbs, and a piece of plastic silverware on the floor in the hallway where the freezer and refrigerator were kept. Behind the ice machine, which was located in the same area there was an accumulation of dust, dirt and a disposable plastic cup. Additionally, food crumbs were observed inside the microwave. 2. Observation of the freezer revealed three sheet pans containing frozen breadsticks, and a bag containing cooked hamburger patties that were not labeled with a date or time. Additional items not labeled with a date or time found in the refrigerator included three steam…

    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 · E2020-01-15 · 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 and interview the facility failed to provide a safe, functional, sanitary and comfortable environment for all residents. This affected 27 (Resident #13, #21, #22, #26, #33, #35, #43, #48, #52, #63, #67, #79, #81, #93, #96, #100, #104, #107, #112, #123, #129, #130, #131, #131, #133, #138, #147) currently residing on the 600 unit. The facility census was 147. Findings include: 1. Observation on 01/12/20 at 10:09 A.M. of the 600 hallway between rooms [ROOM NUMBERS] revealed an overwhelming, highly offensive, musky, odor lingering in hallway. Interview on 01/12/19 at 3:34 P.M. with 10:56 A.M. with Licensed Practical Nurse (LPN) #455 verified the odor was presently strong and was persistent, but fluctuated from weak to strong. Interviews from 01/13/20 at 3:30 P.M. through 01/15/19 at 10:33 A.M. with staff five staff members Licensed Practical Nurse (LPN) #454, LPN #451, State Tested Nurse Aide (STNA) #492 and STNA #529 revealed the residents in rooms [ROOM NUMBERS] (Residents #63, #93, #43 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-15 · 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 interview and record review the facility failed to develop and implement an individualized meal plan to meet Resident #22's needs. This affected one (Resident #22) of eight residents reviewed for nutrition. Findings include: Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including Huntington's disease, gastroesophageal reflux disease, dysphagia, anxiety disorder, dementia with behavioral disturbance, mild protein calorie malnutrition, mood disorder, chronic migraines and major depressive disorder. Review of the comprehensive assessment (MDS 3.0) dated 10/03/19 indicated Resident #22 was alert, oriented and independent in daily decision making ability. He had indications of delusions and rejected care on one to three days of the assessment period. He required supervision and setup help only for eating. He was provided a therapeutic diet. Review of the nutrition assessment dated [DATE] indicated Resident #22 had a body mass index of 19. Supplement…

    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 · D2020-01-15 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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, interview, and policy review the facility failed to ensure medication was properly administered via a percutaneous endoscopic gastrostomy (peg) tube. This affected one resident (Resident #139) of four residents observed for medication administration. There was only one resident identified with a gastrostomy tube in the facility. Findings include: Resident #139 was admitted to the facility on [DATE]. His admitting diagnoses included type II diabetes, cerebral infarction, aphasia, epilepsy, hypertension, Alzheimer's disease and adult failure to thrive. Review of a Minimum Data Set, dated [DATE] revealed the resident had moderate cognitive impairment and was totally dependent on staff for eating due to the resident having a peg tube (a tube inserted into the abdomen for the purpose of providing medications and nutrition for those unable to take these by mouth). Review of the physician order dated 08/08/18 revealed the resident was to receive liquid Potassium Chloride (a…

    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

“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 FOUNDATIONS HEALTH SOLUTIONS — 64 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 54.1-1.1 vs chain
Health inspection 3 of 53.9-0.9 vs chain
Staffing 1 of 52.3-1.3 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 63 homes this chain runs (chain average 4.1★, per CMS)
1 of 5Inniswood Health and RehabilitationWesterville, OH 2 of 5Canterbury Villa Of AllianceAlliance, OH 2 of 5Park Health CenterSt Clairsville, OH 2 of 5Tuscany GardensPataskala, OH 2 of 5Veranda Gardens Nursing & Rehabilitation CenterCincinnati, OH 3 of 5Arlington Care CenterNewark, OH 3 of 5Bennington Glen Nursing & Rehabilitation CenterMarengo, OH 3 of 5Cumberland Pointe Care CenterSt Clairsville, OH 3 of 5Emerald Pointe Health And Rehab CtrBarnesville, OH 3 of 5Home At Taylor's PointeCincinnati, OH 3 of 5McNaughten Pointe Nursing And RehabColumbus, OH 3 of 5Meadow Grove Transitional CareGrove City, OH 3 of 5The Gables Of Marysville Health And RehabilitationMarysville, OH 3 of 5The Gardens Of Fairfax Health Care CenterCleveland, OH 3 of 5Timberland Ridge Nursing & RehabilitationFairlawn, OH 4 of 5Austin Trace Health And RehabilitationCenterville, OH 4 of 5Batavia Nursing Care CenterBatavia, OH 4 of 5Claymont Health And RehabilitationUhrichsville, OH 4 of 5Crown Pointe Care CenterColumbus, OH 4 of 5Florentine GardensLoveland, OH 4 of 5Hickory Creek Of AthensThe Plains, OH 4 of 5Jefferson Healthcare CenterJefferson, OH 4 of 5Lafayette Pointe Nursing & Rehab CtrWest Lafayette, OH 4 of 5Maria Joseph Living Care CenterDayton, OH 4 of 5Mill Creek Nursing & RehabilitationGalion, OH 4 of 5Respiratory And Nursing Center Of DaytonMoraine, OH 4 of 5Sycamore Run Nursing And Rehab CtrMillersburg, OH 4 of 5Waterview Pointe Nursing & RehabilitationMarietta, OH 4 of 5Woods On French Creek Nursing & Rehab Center TheAvon, OH 5 of 5Admirals Pointe Nursing & RehabilitationHuron, OH 5 of 5Brunswick Pointe Transitional CareBrunswick, OH 5 of 5Capri GardensLewis Center, OH 5 of 5Carington ParkAshtabula, OH 5 of 5Concord Health & Rehab CtrWheelersburg, OH 5 of 5Concord Ridge Health And RehabilitationMentor, OH 5 of 5Country View Of SunburySunbury, OH 5 of 5Darby Glenn Nursing And Rehabilitation CenterHilliard, OH 5 of 5Glen MeadowsHamilton, OH 5 of 5Golden Years Nursing CenterHamilton, OH 5 of 5Highbanks Care CenterColumbus, OH

Showing 40 of 63; lowest-rated first.

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 / managerTypeRoleSince
COLLERAN, BRIANIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
KRYSTOWSKI, JOHNIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2018
FOUNDATIONS HEALTH SOLUTIONS, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
MOTOC, ADINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/09/2024
SMITH, MARKIndividualADP OF THE SNFsince 06/01/2018

CMS files one row per role, so the 12 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

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.

$14.2M
Net patient revenuemost recent cost report
+0.5%
Operating marginrevenue minus expenses
$2.0M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 24%Medicare 0%Other / private 75%

This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$273per resident / day
operating cost
$8,299per month
≈ monthly operating cost
$274per 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 365134. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-14, 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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