Regency Care Of Copley
2631 Copley Road, Akron, OH 44321 · For profit - Limited Liability company · 70 certified beds · (330) 666-2631 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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
- it has a citation for mishandling residents’ money or property (F0569)
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 5 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.2% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 7.9% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.1% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 52.1% | 30.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.5% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.6% | 6.1% | 16.1% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 27.2% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.6% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 16.4% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 8.8% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not 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 SNF | not 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 discharge | not 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 discharge | not 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 discharge | not 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 identified | not 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 setting | not 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 discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not 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 worsened | not 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 hospitalization | not 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 SNFs | not 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
How full it usually is: this home is certified for 70 beds and averages 49.5 residents a day — about 71% occupied, or roughly 20 beds typically open. It usually has some room. 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 3.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.00 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.43 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 3.35 hrs/resident/day on weekends vs 4.18 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.05 to 0.85 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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
Deficiencies are fewer than at the previous inspection — improving. 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.
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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Dcited before2025-12-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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, interview, record review, and facility policy review, the facility failed to provide adequate and timely activities of daily living (ADL) care for dependent residents. This affected one resident (#42) of three residents observed and reviewed for ADL care. The facility census was 51.Findings include: Review of Resident #42 ' s medical record revealed an admission date of 10/25/24. Diagnoses included quadriplegia, muscle weakness, and anoxic brain injury.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had no cognition score as the resident was noted to be rarely/never understood. Resident #42 was dependent with toileting and bed mobility and was incontinent of bowel and bladder.Review of the care plan dated 07/14/25 revealed Resident #42 was dependent with bathing and care. Interventions included to turn and reposition as needed and to provide two staff assistance with bathing.Observation on 12/01/25 at 8:41 A.M. reveled Resident #42 was in bed on her left…
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.
- Potential for harm · Dcited before2025-12-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 provide timely incontinence care to residents. This affected two residents (#27 and #42) of three residents observed and reviewed for incontinence care. The facility census was 51.Findings include:1.Review of Resident #27's medical records revealed an admission date of 11/14/24. Diagnoses included stroke with left-sided weakness, muscle weakness, and need for personal care assistance.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had impaired cognition. Resident #27 was dependent on staff for toileting and was noted to be incontinent of bowel and bladder.Review of the care plan dated 11/17/25 revealed Resident #27 had activities of daily living deficits. Interventions included to provide toileting assistance as required.Observation on 12/01/25 at 8:45 A.M. revealed Resident #27's call light was active. Upon entering Resident #27's room, an odor of stool was detected 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.
- Potential for harm · D2025-08-12 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond 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 record review, observation, interview, review of nursing schedules for 07/15/25 through 07/21/25, review of the purchase order and receipt from facility maintenance, review of facility policies, and review of the facility investigation of self-reported incident (SRI) number 263186, the facility failed to ensure a thorough investigation and documentation was completed related to allegations of inadequate care of Resident #4 who had a tracheostomy. This affected one (Resident #4) of two residents reviewed for tracheostomy care and had the potential to affect two (Residents #4 and #23) identified by the facility with tracheostomies. The facility census was 46. Findings include:Review of the medical record for the Resident #4 revealed an admission date of 01/10/25 with diagnoses including acute respiratory failure with hypoxia, cerebral infarction, type two diabetes mellitus, atrial fibrillation, paranoid schizophrenia, post-traumatic subdural hemorrhage, lymphangioma, sepsis, encephalopathy, gastrostomy…
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.
- Potential for harm · D2025-08-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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, medical record review, review of facility policies, and review of the facility investigation of self-reported incident (SRI) number 263186, the facility failed to ensure appropriate care and services were provided to Resident #4, who had a tracheostomy. This affected one resident (Resident #4) of two residents (residents #4 and #23) who were reviewed for appropriate tracheostomy care. The facility census was 46. Review of the medical record for Resident #4 revealed an admission date of 01/10/25 with diagnoses including acute respiratory failure with hypoxia, cerebral infarction, type two diabetes mellitus, atrial fibrillation, paranoid schizophrenia, post-traumatic subdural hemorrhage, lymphangioma, sepsis, encephalopathy, gastrostomy status, and encounter for attention to tracheostomy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 07/10/25 revealed Resident #4 had severely impaired cognition and was dependent for all activities of daily living (ADL),…
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.
- Potential for harm · D2024-04-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, record review and interviews, the facility failed to provide adequate supervision to prevent exit seeking behavior and elopement for Resident #40 and a fall for Resident #11. This affected two (Residents #11 and #40) of two residents reviewed for accident hazards. The facility census was 51. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 03/01/24 with diagnosis including late onset Alzheimer's Disease, dementia, anxiety and depression. Her medical record contained a photograph so that she was identifiable to staff. Review of the admission Elopement assessment dated [DATE] revealed Resident #40 was mobile and had unsafe wandering prior to coming to the facility. Review of the Elopement assessment dated [DATE] revealed Resident #40 was at risk for elopement due to being cognitively impaired, making poor decisions, exit seeking and having a history of an actual elopement or unsafe wandering. Review of the physician's orders dated 03/04/24…
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.
- Potential for harm · Ecited before2022-10-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 interview and observation, the facility failed to ensure the kitchen was maintained in a clean, sanitary manner. This had the potential to affect 47 of the 49 residents, excluding Resident #18 and Resident #39, who received nothing by mouth. Findings included: Observation of the kitchen on 10/03/22 at from 9:30 A.M. to 10:15 A.M. revealed the following: - Dietary Aide #522 was standing inside kitchen by the entrance door with no hairnet on. - The hood above the stove had brown drip spots on the outside of it - The wall behind the stove had numerous amount of brown drip stains on it. - [NAME] colored stains were noted on the outside of the upper steamer. - In the walk in cooler, there was a plastic canister with strawberry glaze in it that was not dated - There was paper, dirt and debris noted under the main freezer - The counter across from the stove that had a shelve below it was noted to have large bowls, and metal baking sheets and the shelve was noted to have a white colored shelve paper on it that had brown stains, and food crumbs on it. - Observation of the large…
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.
- Potential for harm · E2022-10-07 · tag F0880 — failed to prevent and control infections — patternProvide 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, medical record review, and policy review, the facility failed to ensure proper infection control was maintained throughout the facility related to COVID-19 and catheter care. This affected 41 of 49 residents residing in the facility as eight residents were identified as COVID-19 positive (Resident #1, #33, #40, #19, #150, #5, #45, #16). Findings include: 1. Review of Resident #150 medical record revealed an admission date of 09/09/22. Review of Resident #150's October 2022 physician orders revealed an order dated 09/26/22 for the resident to be on droplet precaution isolation every shift for 10 days due to being positive for COVID-19. Observation on 10/03/22 at 11:54 A.M. revealed State Tested Nursing Aide (STNA) #566 walk into Resident #150's room without eye protection, collected trash, removed her gown and gloves, exited the room, and walked down the hall. Upon exiting the room she did not put on a clean N-95 Mask. Interview on 10/03/22 at 11:55 A.M. with STNA #566 confirmed that she did not have eye protection on when entering Resident #150's…
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.
- Potential for harm · E2022-10-07 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and policy review, the facility failed to timely vaccinate residents for COVID-19 after consents were signed to receive the vaccine. This affected four residents (Resident #19, Resident #29, Resident #33, and Resident #48) out of five unvaccinated residents reviewed for vaccinations. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 04/29/22. Review of Resident #19's COVID=19 immunization form revealed a consent was signed on 04/29/22 verifying the resident wanted to receive the COVID-19 vaccine. Review of the Resident #19's nursing notes revealed the resident tested positive for COVID-19 on 09/26/22 and was unvaccinated against COVID-19. Interview on 10/06/22 at 10:52 A.M. with Director of Nursing (DON) confirmed Resident #19 did not timely receive COVID-19 vaccinations after consenting to receive the vaccinations. 2. Review of Resident #29's medical record revealed an admission date of 08/08/22. Review of Resident #29's COVID-19 immunization form revealed a consent was signed on 08/19/22 verifying 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.
- Potential for harm · D2022-10-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, medical record review, and policy review, the facility failed to thorough assess Resident #33's pressure ulcer, notify the physician of the pressure ulcer, and timely initiate wound treatment. This affected one resident (Resident #33) out of two residents reviewed for pressure ulcers. Findings include: Review of Resident #33 medical record revealed an admission date of 05/19/22 with diagnoses including morbid obesity due to excess calories, diabetes mellitus type two, and stage four pressure ulcer to the residents coccyx. Review of Resident #33's Nursing Note, dated 6/30/2022, revealed the nurse was notified of open areas to the residents buttocks. The resident's left buttock area measured 1.6 centimeter (cm) by 1.6 cm and an open area on right buttock measured 0.5 cm x 2.0 cm. The areas were cleaned and cream applied. The note did not indicate the physician or family were notified. Review of Resident #33's June and July 2022 Physician orders revealed that the facility did not seek treatment for the residents open areas until 07/04/22. Orders…
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.
- Potential for harm · Dcited before2022-10-07 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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
Based on record review, observation, and interview, the facility failed to ensure Resident #18's head was elevated per the physician's order while receiving continuous tube feeding. This affected one resident (Resident #18) of one resident reviewed for enteral feedings. Findings include: Review of the medical record for Resident #18 revealed an admission date of 03/09/18 with diagnoses including dysphagia (difficulty swallowing), anoxic brain damage (damage due to lack of oxygen) and quadriplegia (paralysis to all four limbs). Review of the physician's order dated 03/13/22 revealed she had an order for Isosource enteral feed (type of tube feeding) to run at 50 milliliters (mL) per hour continuous via peg tube. Resident #18 also had a physician's order dated 08/05/22 for the head of the bed to be elevated 30 to 45 degrees when not providing care to prevent aspiration from tube feeding. Review of her care plan dated 03/14/18 revealed Resident #18 required a tube feeding via peg tube related to anoxic brain damage and inability to swallow effectively. Interventions included to have 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.
Show the remaining 16 citations
- Potential for harm · D2022-10-07 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 interview, observation, medical record review, and facility policy review, the facility failed to ensure medication error rate was less than five percent. There were 12 medication errors out of 31 opportunities, resulting in a 38.71 percent medication error rate. This affected one Resident (Resident #11) out of six residents reviewed for medication administration. Findings include: Review of the medical record for Resident #11 revealed he was admitted on [DATE] with diagnoses including diabetes mellitus, hypertension (high blood pressure) and hemiplegia (paralysis to his right side). Review of the physician's order dated 01/28/21 for Resident #11 revealed nursing was to administer his morning medications after breakfast. He also had physician's orders dated 01/05/21 for Allopurinol 100 milligrams (mg) (medication for gout), Amlodipine Besylate 10 mg (medication for hypertension), Cholecalciferol 2000 units (Vitamin D supplement), Cilostazol 50 mg (medication for peripheral vascular disease),…
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.
- Potential for harm · Dcited before2022-10-07 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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 expired medications were removed from the medication cart and the medication storage room. This affected one resident (Resident #11) but had the potential to affect all residents residing in the facility. Findings include: Observation and interview on 10/04/22 at 7:46 A.M. with Licensed Practical Nurse (LPN) #536 during the medication administration for Resident #11, revealed she was unable to administer Aspirin 325 milligrams (mg) as it was not available in her medication cart on the Emerald Unit. LPN #536 went to the medication storage room where it was observed that eight of eight bottles of Aspirin 325 mg had the expiration date of August 2022. LPN #536 verified all eight bottles were expired. LPN #536 then went to the medication cart on the Sapphire Unit where LPN #565 verified the bottle of Aspirin 325 mg in her cart had the expiration date of August 2022. There were no other available bottles of Aspirin 325 mg in the facility. Facility policy review titled, Medication Storage, 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.
- Potential for harm · F2019-10-17 · tag F0607 — failed to have anti-abuse policies — widespreadDevelop 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
Based on staff interview, review of personnel files and the abuse policy and procedure, the facility failed to implement policies and procedures including screening of all employees against the State of Ohio Nurse Aide Registry to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property and failed to obtain reference checks. This affected four (Housekeeping Staff #60, #62 and #63 and Dietary Aide #61) of personnel files reviewed. This had the potential to affect all 58 residents in the facility resulting in substandard quality care. Findings include: Review of 12 personnel files revealed four staff were not checked against the State of Ohio Nurse Aide Registry. Review of three Housekeeping Staff (#60, #62 and #63) and Dietary Aide #61 lacked evidence they were screened against the State of Ohio Nurse Aide Registry for negative findings. State Tested Nurse Aides (STNA) #64, #65 and #66, Registered Nurses (RN) #67 and #71 and Licensed Practical Nurses (LPN) #68, #69 and #70 had evidence they 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.
- Potential for harm · Fcited before2019-10-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 maintain a clean and sanitary kitchen. This affected all residents who take food by mouth. The facility census was 58. Findings include: The initial tour of the kitchen was conducted with the Dietary Manager (DM) #404 on 10/15/19 at 8:45 A.M. The DM #404 verified the following: the walk in cooler had a container the DM #404 identified as containing coleslaw and another with vegetables that was not labeled or dated. A milk carton and dried spilled milk was on the floor in the walk in cooler. A cup was stored in a container the DM #404 identified as thickener. The large stand mixer was heavily splattered with a dried beige substance on the splash guard, turning mechanism and outside of the bowl. The whish attachment stored in the bowl also had areas of dried food debris. Two Vulcan ovens were heavily rusted on the outside. There was a moderate amount of food debris on the floor of the oven. The back covers were stained and had oily drips over the flat top. The space between the flat top and the burners had black…
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.
- Potential for harm · F2019-10-17 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of pest control documentation, the facility failed to maintain a pest free environment. This affected all 58 residents in the facility. Findings include: The kitchen was observed on 10/15/19 at 8:45 A.M. There were small winged flying insects near the dish washing area and around the steam table. Interview with Dietary Manager (DM) #420 on 10/15/19 at 9:00 A.M. said they had a problem with gnats. She said after each meal she puts bleach down the drains and was not able to eliminate the gnats. A subsequent visit to the kitchen on 10/16/19 at 11:00 A.M. revealed gnats were still flying around the kitchen. Interview with Director of Maintenance #104 on 10/16/19 at 2:50 P.M. said they have monthly pest control who treat the kitchen for gnats, and the Dietary Manager also does a bleach treatment after every meal. Review of the pest control service reports indicated the facility was treated for flying insects monthly. The service report dated 04/29/19 indicated the kitchen had an accumulation of food product in grout lines from damaged goods…
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.
- Potential for harm · E2019-10-17 · tag F0569 — patternNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and review of resident funds, the facility failed to have evidence Resident's #20, #41, #49 and #54 and/or representative were notified when their account reached $200.00 less than the Medicaid resource limit which could result in loss of Medicaid benefits. This affected four of six residents reviewed for personal funds. Findings include: The review of resident funds was conducted with Business Office Manager (BOM) #420 on 10/16/19 at 2:45 P.M. who verified the total in four resident account exceeded the Medicaid resource limit. Resident #20 had $16,570.49, Resident #41 had $10,460.21, Resident #54 had $2356.65, and Resident #49 had $3086.00 in their accounts. Interview with BOM #420 on 10/16/19 at 3:25 P.M. confirmed the facility had no evidence the residents/representatives were notified when their accounts reached $200.00 less than the Medicaid resource limit.
- Potential for harm · E2019-10-17 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 — the official record, unedited, may be distressing
Based on observation, record review and interview, the facility failed to provide a home like environment. This affected Residents #11, #12, #15, and #48 of 58 residents who reside in the facility. Findings: Environmental tour was conducted with Maintenance Director (MD) #104 on 10/17/19 from 8:25 A.M. to 8:50 A.M. Resident #11's base board padding under the sink had peeled away from the wall exposing the wall and tile flooring. Resident #12's room contained wall damage by the bed, Resident #15's tube feed pole was dirty, and Resident #48's door to the room had significant damage by the door handle where the catch lock meets when closing the door. Review of the maintenance request log did not reveal any work orders for the rooms that were inspected. Interview with the MD #104 on 10/17/19 at 8:50 A.M. confirmed the above findings.
- Potential for harm · Ecited before2019-10-17 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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, staff interview, review of manufacture guidelines and review of the facility policy, the facility failed to discard expired culture tubes in the Emerald unit medication room and Lantus insulin for Resident #5. This had the potential to affect 29 residents (Resident #28, #33, #42, #9, #54, #49, #16, #52, #36, #19, #45, #57, #47, #35, #59, #23, #13, #44, #259, #26, #7, #29, #5, #25, #50, #38, #6, #56 and #10) on the Emerald unit and Resident #5 on the Sapphire unit. Findings include: 1. Observation on [DATE] at 8:35 A.M. of the Emerald unit Medication storage room with Registered Nurse (RN) #405 revealed 23 Remel Micro Test M6 culture tubes with the expiration date of [DATE]. An interview at this time, RN #405 verified the culture tubes were expired. 2. Observation on [DATE] at 10:05 A.M. of the Sapphire unit medication cart with Licensed Practical Nurse (LPN) #401 revealed a 10 milliliters (ml) multiple dose vial of Lantus insulin for Resident #5 had an opened dated on [DATE] (36 days). An…
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.
- Potential for harm · D2019-10-17 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review and policy review, the facility failed to have consistent documentation related to Resident's #47 and #54's wishes related to life-sustaining treatments. This affected two of 24 records during the screening process. Findings include: 1. Review of the medical record revealed Resident #47 was on Hospice services. The medical record had a clear sleeve under the advanced directives tab that had a white sheet of paper indicating DNRCC (do not resuscitate comfort care) and the other side of the clear sleeve was a green sheet indicating DNRCCA (do not resuscitate comfort care arrest). The electronic medical record had DNRCCA in the current physician orders. Review of the Hospice binder contained a DNRCCA form. 2. Review of Resident #54's medical record contained a form under the advanced directives sleeve indicated DNRCCA; however, the electronic medical record current physician orders indicated the resident desired to be Full Code status. Interview with the corporate nurse on 10/17/19 at 9:22 A.M. indicated the nurse should look in the hard chart 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.
- Potential for harm · D2019-10-17 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — the official record, unedited, may be distressing
Based on recorded review and interview, the facility failed to provide the correct Quality Improvement Organization Appeal information (QIO) on their Notice of Medicare Non-Coverage letter for Residents #32 and #53. This affected two of three residents reviewed for notice of Medicare Non-Coverage. The facility census was 58. Findings include: Review of the Notice of Medicare Non-Coverage letter (NOM-NC), revealed Residents #32 and #53 letters were sent by certified mail within the required time frame. Further review revealed both letters were not updated with the new QIO information for appeals. Interview with Social Worker (SW) #103 on 10/17/19 at 10:00 A.M. confirmed the findings.
- Potential for harm · Dcited before2019-10-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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, interview and record review, the facility failed to provide personal hygiene and bathing services for Resident's #30 and #35 who were dependent on staff for activities of daily living. This affected two Residents (#30 and #35) of five Residents (#5, #15, #30, #35 and #52) reviewed for activities of daily living. The facility census was 58. Findings include: 1. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including open wound right lower leg, Methicillin resistant staphylococcus aureus infection, morbid obesity, Parkinson's disease, heart failure, diabetes, chronic pain, dementia without behaviors, major depressive disorder, schizophrenia, peripheral vascular disease and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was severely cognitively impaired and was totally dependent on one person for bathing. Review of the activity of daily living plan of care indicated…
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.
- Potential for harm · D2019-10-17 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 observations, medical record review and staff interview, the facility failed to provide restorative nursing programs as recommended by the physical therapist. This affected one resident (Resident #15) of two reviewed for mobility and a decline in activities of daily living. The facility census was 58. Findings include: Review of a medical record revealed Resident #15 was admitted to the facility on [DATE] withe the diagnoses of anoxic brain damage, quadriplegia, dysphagia, contractures of muscle at multiple sites, spinal stenosis, gastrostomy, chronic respiratory failure and poisoning by heroin. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had severely impaired cognition, required total dependence of two staff members for bed mobility, transfers, dressing, toilet use, required one staff member for personal hygiene and was not on restorative programs. She was always incontinent of bowel and bladder. Observation on 10/16/19 at 9:14 A.M. revealed 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.
- Potential for harm · Dcited before2019-10-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 medical record review and staff interview, the facility failed to provide Resident #32 with intervention to prevent constipation. This affected one resident (Resident #32) of five reviewed for unnecessary medications. The facility census was 58. Findings include: Review of a medical record revealed Resident #32 was admitted to the facility on [DATE] with the diagnoses of dementia, anxiety disorder, osteoporosis, and muscle weakness. Review of the 60-day Minimum Data Set (MDS) 3.0 assessment revealed Resident #32 had severely impaired cognition, required extensive assistance of two staff members for transfers and one staff member for toilet use. The resident was frequently incontinent of bowel and bladder. Observation on 10/15/19 at 9:30 A.M. Resident #32 was moaning and complaining of her belly hurting. She indicated she had to go to the bathroom, and she had not had a bowel movement for four days. Review of the October 2019 physician's orders revealed an order dated 09/30/19 for 100 milligrams (mg) 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.
- Potential for harm · Dcited before2019-10-17 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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 medical record review and staff interview, the facility failed to timely address Resident #15's weight loss. This affected one resident (Resident #15) of two residents reviewed for nutrition. The facility census was 58. Findings included: Review of a medical record revealed Resident #15 was admitted to the facility on [DATE] with the diagnoses of anoxic brain damage, quadriplegia, dysphasia, contractures of muscle at multiple sites, spinal stenosis, gastrostomy, chronic respiratory failure and poisoning by heroin. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had severely impaired cognition, required total dependence of two staff members for bed mobility, transfers, dressing, toilet use, required one staff member for personal hygiene and was not on restorative programs. She was always incontinent of bowel and bladder. The resident had not had a weight loss or gain and received enteral tube feeding. Review of the October 2019 physician's order revealed…
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.
- Potential for harm · D2019-10-17 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
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 interviews, the facility failed to obtain physician's order laboratory tests for Resident #30. This affected one (Resident #30) of 23 residents records reviewed. The facility census was 58. Findings include: A medical record review revealed Resident #30 was admitted to the facility on [DATE] with the diagnoses of chronic ischemic heart disease, dementia, cerebral infarction, major depressive disorder, noncompliance, psychosis, mild cognitive impairment, anemia and schizophrenia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had severely impaired cognition and required extensive assistance of one staff member for all activities of daily living. The resident was always incontinent of bowel and bladder. Review of the October 2019 physician's orders revealed Resident # 30 had an order dated 09/12/19 to obtain three stool samples for occult blood. Review of laboratory tests dated 09/12/19 revealed Resident #30 had a low…
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.
- No harm found · C2019-10-17 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and review of the Quality Assessment and Assurance (QAA) Committee attendance records, the facility failed to ensure the QAA committee ensured the Medical Director or his/her designee attended the quarterly QAA meetings. This had the potential to affect all 58 residents. Findings include: Review of the two QAA attendance records dated 04/30/19 and 07/30/19 verified the Medical Director nor his designee attended the meetings to provide valuable perspective in identifying, analyzing and correcting problems in resident care areas and other areas affecting the facility. Interview with the Administrator on 10/15/19 at 10:30 A.M. during the entrance conference and further interview with the Administrator during the QAA interview on 10/17/19 at 4:49 P.M. verified the Medical Director nor his designee attended the quarterly QAA meetings.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2024-06-14 for 19 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| KOTHARI, ZAHID | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 6% | since 01/01/2024 |
| MELTON, DAVID | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 6% | since 01/01/2024 |
| WOODWARD, MELVIN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 88% | since 10/01/2021 |
CMS files one row per role, so the 10 rows in the source record cover these 3 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.
About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $895K paid to related parties — landlords or management companies under common ownership — equal to about 13% 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
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
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.
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 365320. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-02, 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.