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Altercare Of Alliance Ctr For Rehab & Nc INC

11750 Klinger Avenue NE, Alliance, OH 44601 · For profit - Corporation · 96 certified beds · (330) 823-8263 Medicare & Medicaid certified

Call the home — (330) 823-8263 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jul 2024Resident-funds citation (F0569)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, 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
  • 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
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
405 S Linden Ave # 210 · (330) 821-3961 · Call to confirm hours
Pharmacy
Pharmacy2.7 mi
1800 W. State
Grocery
299 W Main St · (330) 821-2860 · Call to confirm hours
Park
Mahoning Valley Trail · Typically dawn to dusk
Place of worship
14289 Edison St NE · (330) 821-3265

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
Short-stay residentsrehab / post-hospital 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 1 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.6%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight5.0%6.2%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms23.0%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.2%3.2%3.3%worse
Long-stay residents whose ability to walk worsened5.2%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication31.3%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine88.0%94.5%95.3%typical
Long-stay residents with pressure ulcers5.9%3.4%4.7%worse
Long-stay residents with worsening bladder/bowel control21.2%21.4%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table2.3%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication2.4%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine34.1%75.6%79.4%worse
Short-stay residents rehospitalized after admission14.9%24.9%22.6%better
Short-stay residents with an outpatient ER visit8.7%12.9%12.0%better

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.

51.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.7%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
66.7%U.S. median 56.6%
Met the expected recovery
0.45U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 66.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 33 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.45 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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 SNF51.7%CMS range 42.5–60.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 6.8–14.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge66.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge57.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge39.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 3.7–14.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.051.02Oct 2022–Sep 2024CMS makes no comparison for this 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

0.58
RN hours/ resident / day
0.89
LPN hours/ resident / day
2.38
Aide hours/ resident / day
3.85
Total nurse hours/ resident / day
0.32
RN hoursweekends
55.4%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 96 beds and averages 67.8 residents a day — about 71% occupied, or roughly 28 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 3.85 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 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 3.33 hrs/resident/day on weekends vs 4.07 on weekdays — 18% thinner on weekends. RN hours go from 0.68 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

4
deficiencies at the latest standard inspection (2025-04-03)
15
at the previous standard inspection (2022-10-27)

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.

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.

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 · D2025-04-03 · tag F0569 — isolated
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    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 ensure resident funds were disbursed to the resident's estate within 30 days as required. This affected one (Resident #79) of six residents reviewed for personal funds. The facility census was 73. Findings include: Review of Resident #79's medical record revealed an admission date of [DATE] and diagnoses including dysphagia, weakness, cerebral infarction, dementia without behavioral disturbance and anemia. Resident #79's son was listed as his emergency contact. Resident #79 expired in the facility on [DATE]. Review of the facility resident funds report dated [DATE] revealed Resident #79 had a balance of $92.51. There was a notation that Resident #79 had expired on [DATE] on the report. Review of Resident #79's resident fund statement for [DATE] through [DATE] revealed Resident #79 had an ending balance of $92.51 as of [DATE]. Interview on [DATE] at 4:19 P.M. with Lead Receptionist (LR) #875 revealed the facility's corporate office was responsible for…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-03 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and facility policy, the facility failed to ensure the physician and/or nurse practitioner and family of Resident #78 were notified of a change in condition. This affected one resident (#78) out of 20 residents reviewed for notification of change in condition. The facility census was 73. Findings include: Review of closed medical record for Resident #78 revealed an admission date of 02/07/25 and an expiration date of 02/17/25. Diagnoses included cognitive communication deficit, chronic obstructive pulmonary disease (COPD), complete traumatic amputation of one right lesser toe, essential hypertension (high blood pressure), and dementia. Review of the baseline care plan located in the facility document Clinical admission Documentation 0419-U, dated 02/07/25, revealed Resident #78 had respiratory issues due to history of smoking, pulmonary effusion (collection of fluid around the lungs), and need for oxygen. Approaches included keep head of bed up as tolerated, check pulse oxygen level per order, provide oxygen therapy per order, routine monitoring…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, facility policy review, and review of the National Institute of Health guidance, the facility failed to ensure reusable resident nebulizer masks were bagged to prevent the potential for cross contamination of the nebulizer mask. This affected two (Residents #3 and #46) of three residents (Residents #3, #17 and #46) reviewed for respiratory therapy. The facility census was 73. Findings include: 1. Review of Resident #3's medical record revealed the resident was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), acute on chronic diastolic congestive heart failure (CHF) and chronic respiratory failure with hypoxia (insufficient oxygen supply at the tissue level). Review of Resident #3's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and had no rejection of care. Review of physician orders revealed an order dated 08/25/24 for albuterol sulfate solution (bronchodilator…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-03 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to ensure an accurate accounting and administration of opioid medications. This affected two (Residents #25 and #58) of two residents identified during review of a Self-Reported Incident (SRI) investigation. Findings include: Review of Resident #25's medical record revealed the resident was admitted on [DATE] with diagnoses including bilateral primary osteoarthritis of the knee, other chronic pain and depression. Review of Resident #25's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #25's physician orders revealed an order dated 02/10/25 for oxycodone 10 mg (milligrams) three times a day to be administered at 9:00 A.M., 1:00 P.M. and 6:30 P.M. Review of SRI Tracking Number #258409 dated 03/19/25 revealed there was a medication discrepancy. On 03/19/25 during 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.

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Potential for harm · D2024-07-22 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, facility self reported incident review, interview and policy review the facility failed to report an allegation of medication misappropriation to the Administrator and state survey agency. This affected one (Resident #18) of three residents reviewed for misappropriation. The facility census was 85. Findings include: Review of Resident #18's medical record revealed an admission date of 05/29/24 with admission diagnoses that included cervical radiculopathy, spinal stenosis and chronic pain. An admission Minimum Data Set (MDS) 3.0 assessment with a reference date of 06/05/24 indicated Resident #18 had an intact and independent cognition level. Review of the physician orders revealed the use of tramadol 50 mg every eight hours as needed for pain control. There was no evidence of a physician order for the use of cetirizine noted. Interview with Resident #18 on 07/22/24 at 10:01 A.M. revealed approximately one month ago a nurse provided him a different pill than his prescribed narcotic analgesic medication. Resident #18 further added that he kept the pill…

    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 · D2024-07-22 · 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

    Based on medical record review, facility self reported incident review, interview and policy review the facility failed to investigate an allegation of medication misappropriation. This affected one (Resident #18) of three residents reviewed for misappropriation. The facility census was 85. Findings include: Review of Resident #18's medical record revealed an admission date of 05/29/24 with admission diagnoses that included cervical radiculopathy, spinal stenosis and chronic pain. An admission Minimum Data Set (MDS) 3.0 assessment with a reference date of 06/05/24 indicated Resident #18 had an intact and independent cognition level. Review of the physician orders revealed the use of tramadol 50 mg every eight hours as needed for pain control. There was no evidence of a physician order for the use of cetirizine noted. Interview with Resident #18 on 07/22/24 at 10:01 A.M. revealed approximately one month ago a nurse provided him a different pill than his prescribed narcotic analgesic medication. Resident #18 further added that he kept the pill and advised the Assistant Director 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-03-14 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the facility Payroll Based Journal (PBJ) submission data and staff interview, the facility failed to ensure submission of the Payroll Based Journal data as required. This had the potential to affect all 85 residents residing in the facility. Findings include: Review of the facility Payroll Based Journal (PBJ) submission data report revealed no evidence of data submitted by the facility for fiscal year 2023 for the third quarter (April 1 to June 30). Interview with the facility Administrator on 03/14/24 at 10:40 A.M. revealed the facility corporate office submits the PBJ data. The Administrator verified the lack of PBJ submission and this had been identified by the facility. The facility implemented the following corrective actions: As a result of the incident, the facility took the following actions to correct the deficient practice on 10/31/23: - Corporate Human Resources staff were educated on PBJ submission by the corporation president on…

    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.

    Administration Deficiencies · Past Non-Compliance
  • Potential for harm · Ecited before2023-10-27 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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, interview, record review, and facility policy review the facility failed to store medications properly for Residents #5, #20, #22, and #55 in the medication cart on the South and Speret units. This affected four residents (#5, #20, #22, and #55) of 12 residents (#4, #5, #8, #20, #22, #23, #24, #26, #32, #55, #64, and #69) the South and Speret units who receive narcotic medications. The facility census was 72. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 03/16/20. Diagnoses included Alzheimer's disease, antisocial behavior, and major depressive disorder. Review of care plan for Resident #5 dated 06/14/22 revealed he had aggressive behaviors. Interventions included administering medications as ordered and redirecting Resident #5 from unsafe situations. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severe cognitive impairment with a memory problem. Resident #5 required extensive one-person…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-10-27 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure 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, review of temperature logs, and policy review the facility failed to ensure medications were stored wth proper temperature controls. This had the potential to affect all residents residing in the facility. Findings included: 1. Observation on 10/24/22 at 10:02 A.M., with Licensed Practical Nurse (LPN) #197 revealed the medication refrigerator was 26 degrees Fahrenheit. There were insulins (Levemir (1), Trulicity (3), Lantus (18), Humalog (2), acetaminophen suppository (22), Latanoprost eye drops (1), and one vial of tuberculosis that was stored in the refrigerator door. Observation on 10/25/22 at 7:16 A.M., of the North and Novartis medication refrigerators with the Director of Nursing (DON) revealed the North refrigerator was 32 degrees Fahrenheit and the Novartis was 28-degree Fahrenheit. The DON reported the refrigerated temperatures should be 35 to 41 degrees Fahrenheit according to the refrigerator temperature logs. The Novartis refrigerator contained acetaminophen and bisacodyl suppository, Latanoprost eye drops, insulins (Humalog, Lantus,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-10-27 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of menus, and interview, the facility failed to ensure the appropriate amount of food was served in accordance with menus. This had the potential to affect 72 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #27, #28, #29, #30, #31, #32, #33, #34, #35, #37, #38, #39, #40, #41, #42, #44, #45, #46, #47, #48, #49, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #127, #277, #329, #330, #331) of 79 residents who had orders for regular or mechanical soft texture. The census was 79. Findings include: Review of the menu and spreadsheet for lunch on 10/26/22 revealed items to be served included eight ounces of broccoli chicken [NAME] for all diets except small portion orders (four ounces) and puree (2/3 cup). On 10/26/22 observation of tray line between 12:05 P.M. and 12:11 P.M. revealed staff had four ounce scoops in the broccoli chicken [NAME] (both regular…

    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
Show the remaining 16 citations
  • Potential for harm · E2022-10-27 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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, staffing document review, review of resident council notes, observation, and interviews the facility failed to ensure adequate staffing levels to meet the resident's needs. This affected Residents #2, #31, #55, #59, #65 and had the potential to affect all residents residing in the facility. The facility census was 79. Findings included: 1. Interview on 10/24/22 at 11:29 A.M., with Resident #59 revealed sometimes there was only one staff member per hall. The resident reported she had to wait long periods of time for them to get help especially on night shift and evening shift varied due to she required a hoyer lift (mechanical lift). Resident #59 reported that on Saturday it took four hours to get help to be placed on a bedpan on day shift and two hours on afternoon shift. The resident reported she was usually continent, but was incontinent twice Saturday because she had to wait so long, and it became painful. Interview on 10/24/22 at 11:37 A.M. with Resident #55 revealed there was…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-27 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on medical record review and staff interview, the facility failed to provide resident representative notification after a significant weight loss was found. This affected one (Resident #44) of four residents reviewed for nutritional services. The facility census was 78. Findings include: Review of Resident #44's medical record revealed an admission date of 08/03/20 with diagnoses that included vascular dementia with behaviors, cerebrovascular accident and schizoaffective disorder. Review of Resident #44's weights revealed on 09/07/22 the resident weight was 131.2 pounds. On 09/14/22 the weight was recorded as 115.8 pounds, indicating a 15.4 pound or 13.3% weight loss in a one week period. Review of the medical record including progress notes revealed no evidence of resident representative notification of weight loss on 09/14/22 until the facility was asked about the notification on 10/26/22. Interview with the Director of Nursing on 10/26/22 at 1:05 P.M. verified there was no documentation of resident representative notification of a significant weight loss for Resident #44.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-27 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 review and interview, the facility failed to provide written notification of reasons for transfers to the hospital. This affected one (Resident #59) of three residents reviewed for hospitalization. Findings include: On 10/24/22 at 11:48 A.M., during interview Resident #59 reported she had been in and out of the hospital multiple times, usually related to respiratory issues. Resident #59 stated for a while she was being hospitalized every month. Review of Resident #59's medical record revealed diagnoses including acute and respiratory failure, chronic congestive heart failure, chronic obstructive pulmonary disease, type two diabetes mellitus, iron deficiency anemia and stage three chronic kidney disease. Review of progress notes revealed Resident #59 was sent to the hospital by the facility and admitted [DATE] to 01/14/22, 04/27/22 to 05/02/22, 06/01/22 to 06/08/22, and 07/08/22 to 07/12/22. Resident #59 was also sent to the hospital per her request on 06/17/22. No transfer notices were…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-27 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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, review of bed hold notices, and interview, the facility failed to provide required bed hold notices in a timely manner. This affected one (Resident #59) of three residents reviewed for hospitalization. Findings include: Review of Resident #59's medical record revealed diagnoses including acute and respiratory failure, chronic congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, iron deficiency anemia and stage three chronic kidney disease. A nursing note dated [DATE] at 9:00 A.M. indicated Resident #59 was sent to the emergency room due to abnormal laboratory values, abnormal lung sounds, increased edema, tremors, change in mental status and thrombocytopenia (abnormally low level of platelets). A nursing note dated [DATE] at 3:26 A.M. revealed Resident #59 returned to the facility on [DATE] at 9:00 P.M. Review of a Notification of Bed Hold Days form revealed Resident #59 left the faciity on [DATE] to [DATE] and as of that date…

    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 · D2022-10-27 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure comprehensive assessments were completed a minimum of annually. This affected one (Resident #36) of 21 residents reviewed for assessments. The census was 79. Findings include: Review of Resident #36's medical record revealed diagnoses including dementia, chronic pain syndrome, depression, insomnia, schizoaffective disorder, arthritis, anxiety disorder, and irritable bowel syndrome. Resident #36 was admitted to the facility 07/17/20. Only one comprehensive assessment dated [DATE] was completed. On 10/27/22 at 2:54 P.M., during interview Registered Nurse (RN) #112 stated the last comprehensive assessment done for Resident #36 prior to 09/21/22 was during a previous admission on [DATE].

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-27 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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 medical record review, review of therapy notes, observations, and interviews the facility failed to ensure the resident had a plan of care for contracture and failed to ensure the resident performed independent range of motion (ROM) exercises to prevent decline and maintain function of the contractures. This affected one (Resident #55) of two residents reviewed for position/mobility. Findings included: Record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including contracture of right lower leg and right upper arm, osteomyelitis, diabetes, cognitive communication deficit, muscle weakness, need for assistance with personal care, hemiplegia and hemiparesis, lack of coordination, anxiety, schizophrenia, right foot pain, dementia with behavioral disturbance, restlessness and agitation, disorientation, depression with severe psychotic symptoms, and psychotic disorder with delusions. There was no evidence of a right-hand contracture diagnosis. Review of Resident #55'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility failed to ensure urinary output levels were monitored per orders. This affected one (Resident #65) of one resident reviewed for hydration. Findings included: Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of bladder, diabetes, and chronic kidney disease. Review of Resident #65's current orders dated 10/2022 revealed indwelling catheter to straight drain and to record urinary foley output every shift (three times a day). The resident's orders indicated the resident was at risk for fluid imbalance. Review of Resident #65's medication and treatment administration records dated 10/2022 revealed no evidence of urinary output level. Further review of the records revealed the resident received intravenous (IV) fluids on 10/22/22, 10/24/22 and 10/25/22. Review of Resident #65's foley urinary output levels in the vital report dated 10/01/22 to 10/27/22 revealed the resident's urinary…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-27 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids 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 medical record review, observation, and interview the facility failed to ensure intravenous (IV) fluids were administered per orders. This affected one (Resident #65) of one resident reviewed for hydration. Findings included: Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including hallucination, schizoaffective disorder, diabetes, and chronic kidney disease. 1. Review of Resident #65's orders dated 10/21/22 revealed to administer Sodium Chloride 0.9% parenteral solution one liter intravenous. There were special instruction to administer one-liter normal saline, run at 75 cubic centimeters (cc) an hour. Review of Resident #65's medication and treatment administration records dated 10/2022 revealed the resident received intravenous (IV) fluids on 10/22/22. There was no evidence of the amount of IV fluids administered. Review of Resident #65's nursing progress notes dated 10/21/22 to 10/27/22 with the Director of Nursing (DON) and Corporate Nurse (CN) #410 on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-27 · 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

    Based on medical record review, staff interview, and policy review, the facility failed to provide evidence of ongoing communication with the dialysis provider regarding dialysis care and services. This affected one (Resident #64) of one resident reviewed for dialysis care. The facility identified one resident receiving dialysis services. Findings include: Review of Resident #64's medical record revealed an admission date of 05/06/22 with diagnoses including chronic renal disease with hemodialysis, chronic obstructive pulmonary disease, malignant lung neoplasm, pneumonia, and muscle weakness. Review of Resident #64's Care Plan, dated 05/19/22, revealed resident will receive renal dialysis without complications in coordination with the dialysis center. Review of physician orders, dated October 2022, revealed hemodialysis to be provided three times weekly at the dialysis provider. Further review of the medical record and the dialysis binder revealed no communication documentation with the dialysis provider. During interview on 10/27/22 at 10:10 A.M., Registered Nurse (RN) #204…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-27 · tag F0770 — failed to provide lab services — isolated
    Provide 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, observation, and interview the facility failed to ensure stat laboratory tests were performed timely. This affected one (Resident #65) of two residents reviewed for infection. Findings included: Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including hallucination, schizoaffective disorder, diabetes, and chronic kidney disease. Review of Resident #65's progress notes dated 10/20/22 to 10/23/22 revealed on 10/20/22 at 8:30 P.M. agency was there to collect stat labs for urinalysis and culture and blood cultures. On 10/21/22 at 10:42 P.M., stat labs (Basic Metabolic Panel (BMP) and Complete Blood Count (CBC) were reviewed with Nurse Practitioner (NP) and new orders received to start IV with normal saline to run at 75 cc/hr., Rocephin one gram time one dose, and obtain vital signs every shift. Review of Resident #65's order dated 10/20/22 revealed one order that indicated BMP and CBC and then in parenthesis was typed blood culture times two…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-27 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interview, the facility failed to provide timely extraction of teeth for one (Resident #59) of two residents reviewed for dental status. Findings include: On 10/24/22 at 11:37 A.M., Resident #59 stated the dentist had visited and received approval for her to have her last two teeth pulled but there had been a lack of follow through. Review of Resident #59's medical record revealed diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. A report from the dentist dated 09/30/21 indicated a plan for extraction of teeth #6 and #11. A consent for dental surgery was signed by Resident #59 and dated 10/04/21. A nursing note dated 10/22/21 at 8:08 A.M. indicated the consent for dental surgery was forwarded to the dental provider. Notes from a dental visit dated 04/12/22 indicated Resident #59 continued to need to have teeth #6 and #11 extracted to make dentures. A progress note dated 07/26/22 at 2:13 P.M. indicated the nurse contacted a dental clinic to request orders and information from 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-27 · 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 medical record review and interview the facility failed to ensure new orders were written, medication documented on the medication administration records, and ensure nurses did not sign the Nurse Practitioner name on new orders. This affected one (Resident #65) of two residents reviewed for infections. Findings included: Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including diabetes, chronic kidney disease, anemia, and neuromuscular dysfunction of the bladder. Review of Resident #65's progress notes dated 10/23/22 revealed new orders were received for Rocephin (antibiotic) intramuscular (IM) times one dose, then intravenously for six days. Review of Resident #65's medication administration records (MAR) and orders revealed no evidence the Rocephin IM order was written or administered. Interview on 10/27/22 at 12:45 A.M., with the Director of Nursing (DON) and Corporate Nurse (CN) #410 verified there was no evidence the Rocephin IM order received on 10/23/22…

    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 · D2022-10-27 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview the facility failed to ensure ordered antibiotics met criteria prior to administration. This affected one (Resident #65) of two residents reviewed for infection. Findings included: Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including hallucination, schizoaffective disorder, diabetes, and chronic kidney disease. Review of Resident #65's progress notes dated 10/20/22 to 10/25/22 revealed on 10/20/22 at 8:30 P.M. agency was there to collect stat labs for urinalysis (UA) and culture and blood cultures. On 10/21/22 at 10:42 P.M., stat labs (Basic Metabolic Panel (BMP) and Complete Blood Count (CBC) were reviewed with Nurse Practitioner (NP) and new orders received to start IV with normal saline to run at 75 cc/hr., Rocephin one gram time one dose, and obtain vital signs every shift. There was no evidence the UA or blood cultures were obtained per orders. On 10/23/22 at 2:16 P.M., a different NP ordered Rocephin…

    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 · E2019-10-24 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of Resident #90's medical record revealed an admission date of [DATE] with admission diagnoses of bladder cancer, myocardial infarction and congestive heart failure. Resident #90 was discharged to home on [DATE]. Further review of the medical record found no evidence of hospital readmission during admission to the facility. Review of the MDS 3.0 discharge assessment completed on [DATE] indicated Resident #90 was discharged to an acute hospital. On [DATE] at 3:55 P.M. interview with RN #300 verified the MDS 3.0 assessment for Resident #90 was incorrectly coded as the resident being discharged to an acute hospital when the discharge location was home. 4. Review of Resident #1's medical record revealed an admission date of [DATE]. Further review of the medical record revealed Resident #1 expired in the facility on [DATE]. Review of Resident #1's MDS 3.0 assessments revealed the last assessment completed was a quarterly MDS 3.0 comprehensive assessment with a reference date of [DATE]. There was no evidence…

    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 · D2019-10-24 · 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, medical record review, review of Material Safety Data sheets (MSDS) and interview the facility failed to supervise the whereabouts of a resident on the dementia unit resulting in Resident #29 being located in a storage room unsupervised. This affected one resident (#29) of 22 residents residing on the unit. Findings include: Review of Resident #29's medical record revealed an admission date of 08/01/17. Diagnoses included cognitive communication deficit, history of suicidal ideation, difficulty walking, depression, dementia, history of falling, and cerebrovascular disease. Resident #29 resided in a secured dementia unit. A quarterly Minimum Data Set (MDS)3.0 assessment dated [DATE] indicated Resident #29 was sometimes able to make himself understood and was sometimes able to understand others. Resident #29 was assessed with impaired vision (able to see large print). An assessment of his mental status revealed Resident #29 was severely cognitively impaired. The MDS indicated Resident #29…

    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 · D2019-10-24 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, policy review, manufacturer guidelines review and interview the facility failed to maintain adequate infection control practices related to the use of a shared glucometer to prevent the spread of infection. This had the potential to affect four residents (#34, #57, #58 and #89) of four residents identified to be diabetic and who could use glucometer testing on the 211-222 rooms medication cart. Findings include: On 10/22/19 at 11:30 A.M. Licensed Practical Nurse (LPN) #301 was observed using a glucometer to obtain Resident #34's blood glucose level. The blood glucose level was obtained and LPN #301 returned to the medication cart in the hallway. At 11:33 A.M., LPN #301 used one Clorox wipe to clean the glucometer. LPN #301 wiped the glucometer for approximately three seconds and placed the glucometer back into the top drawer of the medication cart, failing to ensure the glucometer maintained an appropriate contact time with the Clorox wipe. At 11:37 A.M., review of the Clorox wipes with LPN #301 indicated proper disinfection of surfaces required a contact time…

    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

“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 ALTERCARE — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.3-0.3 vs chain
Health inspection 3 of 52.7+0.3 vs chain
Staffing 1 of 52.3-1.3 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 21 homes this chain runs (chain average 3.3★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
TSG NURSING CENTERS, INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/13/2002
GERALD F SCHROER DYNASTY TR UA 12312009 FBO ANDREW M SCHROEROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/15/2015
GERALD F SCHROER DYNASTY TR UA 12312009 FBO GERALD F SCHROER JROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/15/2015
GERALD F SCHROER DYNASTY TR UA 12312009 FBO MATTHEW SCHROEROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/15/2015
GERALD F SCHROER DYNASTY TR UA 12312009 MARGARET S GOODMANOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/15/2015
SUSANNE SCHROER DYNASTY TRUST U/AOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/15/2009
THE SCHROER GROUP, INC.Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2001
MOCK, DOUGLASIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICERsince 09/20/2021
FILM, GEORGEIndividualCORPORATE OFFICERsince 06/01/2018
GOODMAN, JOHNIndividualCORPORATE OFFICERsince 01/01/2003
JOHNSON, KATHYIndividualCORPORATE OFFICERsince 01/01/2010
NUTTER, ORIANIndividualCORPORATE OFFICERsince 10/01/2020
ALTERCARE OF OHIO, INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2001

CMS files one row per role, so the 15 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

8 organizational owners 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.

$8.2M
Net patient revenuemost recent cost report
-1.1%
Operating marginrevenue minus expenses
$829K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 20%Medicare 7%Other / private 73%

This home reported $829K paid to related parties — landlords or management companies under common ownership — equal to about 10% 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

$295per resident / day
operating cost
$8,974per month
≈ monthly operating cost
$292per 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 365402. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-03, 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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