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Fairlawn Haven

407 E Lutz Rd, Archbold, OH 43502 · Non profit - Church related · 99 certified beds · (419) 445-3075 Medicare & Medicaid certified

Call the home — (419) 445-3075 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0607, F0609) — most recent Aug 2022Behavioral-health or dementia-care citations — no harm found (F0744, F0758)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • 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 (F0604, F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
121 Westfield Drive, Suite 1, Archbold, OH 43502, United States · (419) 445-2015 · Call to confirm hours
Pharmacy
201 N Defiance St · (419) 445-4496 · Call to confirm hours
Grocery
1925 S Defiance St · (419) 446-9233 · Call to confirm hours
Park
Holland Street · (567) 444-4555 · Typically dawn to dusk
Place of worship
614 N Defiance St · (419) 446-2150

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 4 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 4 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.

Overall rating5★
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 increased2.5%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight2.7%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms5.6%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 injury6.2%3.2%3.3%worse
Long-stay residents whose ability to walk worsened5.4%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication27.6%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine97.7%94.5%95.3%typical
Long-stay residents with pressure ulcers2.0%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control31.8%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table5.0%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine97.7%75.6%79.4%better
Short-stay residents rehospitalized after admission30.9%24.9%22.6%worse
Short-stay residents with an outpatient ER visit23.0%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.021.731.67better
Long-stay outpatient ER visits per 1,000 resident days1.591.801.80better

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.

59.3% 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 148 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.3%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
91.5%U.S. median 56.6%
Met the expected recovery
0.48U.S. median 0.31
Therapy hours / resident / day
0.22hours / resident / day
Physical therapy
0.22hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 91.5% 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 71 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 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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 SNF59.3%CMS range 49.8–65.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 7.7–14.910.7%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 discharge91.5%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 discharge85.9%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 discharge91.5%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 stay1.2%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 worsened2.3%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 hospitalization5.6%CMS range 2.9–9.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.891.02Oct 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

0.30
RN hours/ resident / day
1.02
LPN hours/ resident / day
2.72
Aide hours/ resident / day
4.04
Total nurse hours/ resident / day
0.26
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 99 beds and averages 93.1 residents a day — about 94% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.04 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.72 is at or above 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 3.79 hrs/resident/day on weekends vs 4.15 on weekdays — 9% thinner on weekends. RN hours go from 0.32 to 0.26 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

6
deficiencies at the latest standard inspection (2025-04-10)
10
at the previous standard inspection (2022-08-12)

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.

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

  • Potential for harm · F2025-04-10 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and review of the facility policy, the facility failed to ensure foods were stored in a manner to prevent spoilage and spoiled foods were discarded. This had the potential to affect all residents receiving food from the kitchen with the exception of one (#244) resident the facility identified that received nothing by mouth. The facility census was 90. Findings include: Observation on 04/07/25 from 7:50 AM to 8:10 A.M. revealed the walk-in cooler contained four containers of fresh strawberries with a whitish fuzzy growth on them, a bag of baby carrots that were open, unlabeled, and undated, and a tray of pastries and brownies that were uncovered, unlabeled, and undated. The tray of pastries and the tray of browns were thrown away and were hard when they were moved on the tray to throw in the garbage can. Interview on 04/07/25 at 7:56 A.M. with Assistant Dietary Manager (ADM) #700 verified strawberries contained mold, and confirmed the opened, unlabeled, and undated bag of baby carrots and the tray of pastries and brownies. ADM #700 further…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-10 · 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, resident and staff interview, resident family interview, and policy review, the facility failed to provide a resident and the resident representative a written bed-hold notice at the time of hospitalization. This affected one (#44) of one resident reviewed for hospitalization. The facility census was 90. Findings included: Review of Resident #44's medical record revealed an admission date of 03/07/25. Diagnoses included complication of left knee internal orthopedic prosthetic devices, left artificial knee joint, and multiple sclerosis. Review of Resident #44's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an intact cognition. Review of Resident #44's most recent care plan revealed the resident may need assistance to coordinate community resources for discharge planning. Interventions included to provide written and verbal instructions at the resident's level of understanding, verbally explain instructions to the resident and family prior to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident family member and staff interview, medical record review, review of staff meeting documents and education materials, facility policy review, and review of a facility job description for certified medication aides (CMAs), the facility failed to ensure staff were working within their scope of practice related to CMAs administering as needed medications. This affected one (#64) of two residents reviewed for pain. The facility census was 90. Findings include: Review of the medical record for Resident #64 revealed she was admitted on [DATE] with diagnoses of congestive heart failure (CHF), diabetes mellitus type two, anxiety, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #64 revealed she was cognitively impaired. At the time of medical record review for Resident #64 an MDS assessment was in progress for a significant change for admission to hospice services. Review of the care plan initiated April 2025 for Resident #64 revealed a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-10 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, and facility policy review, the facility failed to ensure physician orders for pain were maintained to provide effective pain management. This affected one (#86) of two residents reviewed for pain. The facility census was 90. Findings included: Review of Resident #86's medical record revealed an admission date of 01/31/25. Diagnoses included malnutrition and acute renal disease. Review of Resident #86's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact. The resident required scheduled pain medication and opioid use for pain control daily. Review of Resident #86's current care plan revealed she had the potential for pain related to chronic pain, osteoarthritis, and low back pain. Interventions included listening to the resident's concerns, advise the resident to request pain medication before pain becomes severe, and assess complaints of pain and report to the medical doctor. Review of Resident #86's nurses…

    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 · D2025-04-10 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure interventions were implemented to address dementia care and treatment. This affected one (#23) of one residents reviewed for dementia related daily care and stimulation. The facility census was 90. Findings include: Review of Resident #23's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including Alzheimer's disease, dementia, coronary artery disease, hypertension, anxiety disorder, chronic pain, osteoporosis, anemia, major depression, type II diabetes mellitus, atrial fibrillation, and chronic kidney disease stage four. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was assessed with moderately impaired cognition, utilized a walker and wheelchair for mobility, required supervision or touching assistance with activities of daily living (ADLs), was continent of bowel and bladder, received a mechanically altered diet, was not at…

    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 · D2025-04-10 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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, medical record review, review of a menu, review of a meal ticket, and review of the facility policy, the facility failed to offer alternate food choices when the resident did not eat well from the offered meal. This affected one (#42) of three residents reviewed for dining observation. The facility census was 90. Findings include: Review of the medical record for Resident #42 revealed an admission date of 04/26/16 with diagnoses of Alzheimer's disease and dysphagia (difficulty swallowing). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #42 revealed the resident was severely cognitively impaired and required set-up for eating. Review of the current physician orders dated April 2025 for Resident #42 revealed she was ordered a fortified regular diet and for staff to check the refrigerator for homemade meals provided from family, and if food was available from family, please offer the homemade food during mealtime. Review of the care plan…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-08-12 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, review of visitor screening logs, review of resident vaccination status, and review of facility policy, the facility failed to ensure proper infection control practices and procedures were followed for visitor screening and source control to prevent the spread of COVID-19 with the potential to affect 13 (#1, #6, #11, #13, #15, #17, #24, #29, #31, #50, #58, #67 and #76) of 13 residents in the Special Care Unit (memory care). Additionally, the facility failed to ensure clean linen was transported in a sanitary manner with the potential to affect 10 (#40, #70, #177, #178, #179, #180, #182, #183, #184 and #187) of 10 residents on the rehabilitation unit. Lastly, the facility failed to ensure sanitary conditions for one Resident (#61) of three residents reviewed who had a catheter. The facility census was 77. Findings include: 1. Interview on 08/01/22 at 8:00 A.M. of the Administrator revealed the facility was in COVID-19 outbreak status until 08/07/22. Observation on 08/02/22…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-12 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review, and staff interview, the facility failed to assisted residents with dining in a dignified manner. This affected three (#2, #21, and #28) of eight residents observed eating in the South dining room. The census was 77. Findings include: 1. Review of Resident #2's medical record revealed an admission date of 11/26/19. Diagnoses included dysphagia, adjustment disorder with mixed anxiety and depressed mood, chronic kidney disease, bradycardia, and heart disease. Review of the most recent Minimum Data Set (MDS) assessment, completed 07/12/22, revealed Resident #2 was assessed as cognitively intact and required extensive one person physical assist with eating. Review of a nutritional care plan dated 12/02/19 revealed an intervention Resident #2 needed assistance with eating. 2. Review of Resident #21's medical record revealed an admission date of 07/02/15. Diagnoses included Alzheimer's disease with late onset, dementia without behavioral disturbances, dysphagia, hypothyroidism, and essential hypertension. Review of the most recent MDS…

    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 · D2022-08-12 · 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 medical record review, staff interview, and review of a facility policy, the facility failed to timely notify the physician when a resident experienced a change in condition that required a new treatment. This affected one (#62) of two reviewed for changes in condition. The census was 77. Findings include: Review of Resident #62's medical record revealed an admission date of 07/01/22. Diagnoses included pressure ulcer of the sacral region, osteomyelitis, quadriplegia, diabetes mellitus type II, chronic kidney disease, acute kidney failure, anemia, and muscle weakness. Resident #62 was discharged on 07/12/22. Review of an admission Minimum Data Set (MDS) assessment, completed 07/05/22, revealed Resident #62 was assessed with intact cognition, required extensive assistance of at least two staff with bed mobility, was dependent with transfers, and no episodes of rejection of care. Resident #62 was assessed at risk for pressure ulcers and was admitted with three stage four and two unstageable (obscured full-thickness skin and tissue loss) pressure ulcers on admission. Review of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-12 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, staff interview, and resident interview, the facility failed to ensure residents were assessed for the appropriate use of a restraint and free from use of an unnecessary restraint. This affected one (#53) of six residents reviewed for falls. The facility census was 77. Findings include: Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia with behavioral disturbances, major depressive disorder, delirium, and overactive bladder. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #53 had mild cognitive impairment and exhibited no physical, verbal or wandering behaviors. Review of fall risk assessments dated 05/24/22, 07/06/22, and 08/06/22 revealed Resident #53 was at moderate risk for falls. Review of the care plan for Resident #53 revealed the risk for falls due to Resident #53's decreased safety awareness. Interventions for Resident #53 included the use of 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2022-08-12 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is 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 observation, staff interview, medical record review, and review of facility policies, the facility failed to ensure residents with hearing impairments were assisted with placement of hearing aides as care planned and as ordered. This affected one (#25) of one residents reviewed for vision and hearing. The facility identified 23 residents in the facility with hearing aides. The census was 77. Findings include: Review of Resident #25's medical record revealed an admission date of 03/06/20. Findings included Alzheimer's disease with late onset, orthostatic hypotension, diabetes mellitus type II, dementia without behavioral disturbances, major depression, anxiety, and atrial fibrillation. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was assessed with severely impaired cognitive skills for daily decision making, was assessed with minimal hearing difficulty, and wore hearing aids. Review of the Care Area Assessment (CAA) Summary for communication 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review, staff interview, review of State Tested Nurse Aide (STNA) bowel tracking documentation and review of facility policy, the facility failed to ensure residents who were dependent for care received assistance with nail care. This affected one (#177) of two residents reviewed for activities of daily living (ADLs). The facility census was 77. Findings include: Review of the medical record for Resident #177 revealed an admission date of 07/23/22. Diagnoses included cerebral infarction, myocardial infarction, aphasia, multiple fractures of ribs, fracture of nasal bones, chronic obstructive pulmonary disease (COPD), hypertension, and retention of urine. Review of the Minimum Data Set (MDS) assessment, dated 07/29/22, revealed Resident #177 had short and long term memory problems, was severely cognitively impaired, and required extensive assistance with bed mobility, dressing, and personal hygiene. Additionally, Resident #177 was occasionally incontinent of bowel. Review of the plan of care, initiated 07/23/22, revealed Resident #177 had a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-08-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility polices, the facility failed to ensure wounds were assessed and treated in a timely manner and failed to ensure compression garments were applied as ordered. This affected one (#62) of one residents reviewed for non-pressure skin impairments and one (#52) of one residents reviewed for edema. The facility identified three residents in the facility with non-pressure skin impairments. The census was 77. Findings include: 1. Review of Resident #62's medical record revealed an admission date of 07/01/22. Diagnoses included pressure ulcer of the sacral region, osteomyelitis, quadriplegia, diabetes mellitus type II, chronic kidney disease, acute kidney failure, anemia, and muscle weakness. Resident #62 was discharged on 07/12/22. Review of an admission Minimum Data Set (MDS) assessment, completed 07/05/22, revealed Resident #62 was assessed with intact cognition, required extensive two-plus persons assistance with bed mobility, was totally…

    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 · D2022-08-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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, staff interview, and review of a facility policy, the facility failed timely assess pressure ulcers. This affected one (#62) of six residents reviewed for pressure ulcers. The facility identified 10 residents in the facility with pressure ulcers. The census was 77. Findings include: Review of Resident #62's medical record revealed an admission date of 07/01/22. Diagnoses included pressure ulcer of the sacral region, osteomyelitis, quadriplegia, diabetes mellitus type II, chronic kidney disease, acute kidney failure, anemia, and muscle weakness. Resident #62 was discharged on 07/12/22. Review of hospital documents dated 05/20/22, prior to Resident #62's admission to the facility, revealed Resident #62 was admitted with chronic osteomyelitis due to uncontrolled diabetes mellitus, had multiple extensive pressure ulcers with necrotizing fascitis (flesh-eating infection), and three separate infectious organisms discovered in her wounds. Resident #62's wound infections were treated with…

    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 · D2022-08-12 · 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, staff interview and review of facility policy, the facility failed to ensure fall interventions were implemented as care planned. This affected one (#13) of six residents reviewed for falls. The facility census was 77. Findings include: Review of the medical record revealed Resident #13 was admitted on [DATE]. Diagnoses included Alzheimer's disease, history of falling, major depressive disorder, orthostatic hypotension, osteoporosis, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was severely cognitively impaired, required extensive assistance with bed mobility, transfers, and locomotion, and had two or more falls. Review of the plan of care, revised 10/29/20, revealed Resident #13 was at risk for falls. Interventions included assist resident getting in and out of bed, a scoop mattress to bed to define bed parameters, and keep wheelchair at bedside while in bed for safety. Review of the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure physician ordered fluid restrictions were followed and failed to ensure appropriate mechanisms were used to alert staff to residents on fluids restrictions per the policy. This affected one (#45) of one residents reviewed for hydration. The census was 77. Findings include: Review of Resident #45's medical record revealed an admission date of 09/20/20. Diagnoses included Alzheimer's disease with late onset, epilepsy, dementia without behavioral disturbances, hypo-osmolality and hyponatremia, syndrome of inappropriate secretion of antidiuretic hormone, flaccid neuropathic bladder, hallucinations, anxiety, congestive heart failure, and aphasia. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was assessed with moderately impaired cognitive skills for daily decision making and required supervision for eating. Review of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-08-15 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility and the staff interview, the facility failed to ensure outdoor garbage dumpster areas were kept in a safe and sanitary manner. This had the potential to affect 93 of 93 facility residents. The facility census was 93. Findings include: Observation on 08/12/19 at 9:39 A.M. of the outside garbage storage area revealed a large puddle of liquid on the ground around the dumpster. The liquid had a strong, foul, odor that smelled like decomposing garbage. A nine volt battery, used disposable latex gloves, pieces of plastic, and other unidentifiable debris were observed in the liquid. Interview on 08/12/19 at 9:44 A.M. with Dietary Manager (DM) #210 verified the area around the outdoor garbage dumpster had not been cleaned. DM #210 reported it was the maintenance staff's responsibility to ensure the area was kept clean. Review of the facility policy titled, Garbage/Recycling Area Cleaning Schedule dated 08/14/18 revealed the facility would maintain a clean waste environment in the facility's receiving/loading dock area where the garbage…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents wheelchairs were kept clean. This affected one resident, Resident (#71) of two residents reviewed for environmental concerns. The facility identified 56 residents who required assistance with ambulation or assistive devices. The facility census was 93. Findings included: Review of Resident #71's medical record revealed an admission date of 06/03/19. Diagnoses included abnormalities of gait, osteoarthritis, asthma, insomnia, major depressive disorder, unsteadiness on lack of coordination, dysphagia, type II diabetes, hyperlipidemia, spinal stenosis, and osteoarthritis. Review of Resident #71's Minimum Data Set (MDS) assessment, dated 07/04/19, revealed Resident #71 was moderately cognitively impaired. Resident #71 required extensive assistance with bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. Observation on 08/12/19 at 2:12 P.M. of Resident #71's wheelchair found a build up of food crumbs, dust, and debris around the edges…

    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 · D2019-08-15 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility Self-Reported Incident (SRI), medical record review, facility policy review and satff interview, the facility failed to implement the abuse policy on reporting allegations of abuse. This affected one (#9) of one residents reviewed for abuse. The faciltiy census was 93. Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, chronic kidney disease, diabetes and hypertension. Review of the nurse progress note dated 04/15/19 at 4:28 P.M., revealed State Tested Nurse Aid (STNA) #150 reported resident called on her call light and wanted her brief changed. When the STNA's were placing the gait belt on resident, resident became upset and grabbed the STNA in her breast and also pinched her breast. Both STNA's left the room and informed the nurse and management. STNA's were instructed to continue to assist resident with two assist and gait belt. Review of SRI number 171824 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility Self-Reported Incident (SRI), medical record review,facility policy review and staff interview, the facility failed to timely report an allegation of abuse by a resident. This affected one (#9) of one residents reviewed for abuse. The faciltiy census was 93. Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, chronic kidney disease, diabetes and hypertension. Review of the nurse progress note dated 04/15/19 at 4:28 P.M., revealed State Tested Nurse Aid (STNA) #150 reported resident called on her call light and wanted her brief changed. When the STNA's were placing the gait belt on resident, resident became upset and grabbed the STNA in her breast and also pinched her breast. Both STNA's left the room and informed the nurse and management. STNA's were instructed to continue to assist resident with two assist and gait belt. Review of SRI number 171824 revealed Resident #9 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-08-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, facility policy review and staff interviews, the facility failed to follow the physician orders for treatment of a non-pressure skin condition. This failed practice affected one (#87) of one resident reviewed for non-pressure skin conditions. The facility census was 93. Findings include: Review of the medical record for Resident #87 revealed an admission date of 01/02/19, with diagnoses of Parkinson's disease, dementia, repeated falls, depression, anxiety, heart disease, diabetes, hallucinations, seborrheic dermatitis and bulbous pemphigoid (a medical condition which causes blistering of the skin). Review of the nurse progress note dated 08/03/19 at 7:58 A.M., revealed Resident #87 had a new blister located below the left knee. Blister was fluid filled and resident was not showing signs of discomfort at this time. Review of the current physician orders revealed to wash bulbous pemphigoid blister to left knee with soap and water or normal saline and pat dry. Leave open to air, every shift ordered on 08/13/19. Observation on 08/15/19 at…

    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 · D2019-08-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, pharmacist and staff interview, the facility failed to attempt two gradual dose reductions (GDR)of psychoactive medications with in the first year of implementation. This affected one (#67) of five residents reviewed for unnecessary medications. The facility identified 58 residents who receive psychoactive medications. The census was 93. Findings include: Review of Resident #67's medical record revealed an admission date of 08/01/18. Diagnoses included Alzheimer's disease, diabetes mellitus type II, major depression, unspecified psychosis, unspecified mood disorder, anxiety, congestive heart failure, and essential hypertension. Review of a physician order dated 08/01/19 revealed Resident #67 was ordered the antidepressant Zoloft 100 milligrams (mg) by mouth daily and the antidepressant Trazodone 100 mg by mouth every 24 hours as needed. Review of a physician order dated 08/02/19 revealed Resident #67 was ordered the antipsychotic medication Abilify 15 mg by mouth at bedtime. Review of monthly medication regimen reviews for Resident #67 completed 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-15 · tag F0800 — isolated
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review, review of facility policy and staff interview, the facility failed to ensure residents who required mechanically altered diets received the proper nutrition. This affected the two residents (#28 and #78) of two residents the facility identified as receiving pureed diets. The facility census was 93. Findings Include: Observation on 08/13/19 at 8:52 A.M., of the kitchen found the dietary staff were preparing cold sub sandwiches as was indicated on the regular lunch menu. Observation on 08/13/19 at 8:56 A.M., of the kitchen found Dietary Staff (DS) #201 completing the pureed lunch meals. Coinciding interview with DS #201 revealed the facility currently had two residents who received a pureed diet, Resident #28 and #78. DS #201 was observed following the recipe to puree two sub sandwiches. DS #201 added two portions of buns, two portions of ham and turkey, and two portions of cheese into a clear glass blender. DS #201 added 1/4 cup water and pork broth per serving to soften the sub components to puree properly. After the subs were pureed…

    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

“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.

Who owns this facility

Owner / managerTypeRoleSince
EMCH, ANDREWIndividualCORPORATE DIRECTORsince 04/01/2025
FREY, LORIIndividualCORPORATE DIRECTORsince 04/01/2021
KAUZLICK, JOYIndividualCORPORATE DIRECTORsince 04/01/2023
KRUEGER, DEXTERIndividualCORPORATE DIRECTORsince 04/01/2025
MOORE, TODDIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/21/2024
RINGENBERG, BRENTIndividualCORPORATE DIRECTORsince 04/01/2024
ROSE, CYNTHIAIndividualCORPORATE DIRECTORsince 04/01/2024
RUFENACHT, LONNIEIndividualCORPORATE DIRECTORsince 03/19/2019
WAGLER, TIMIndividualCORPORATE DIRECTORsince 03/21/2017
WALKER, KARENIndividualCORPORATE DIRECTORsince 03/21/2017
WARNER, TOMIndividualCORPORATE DIRECTORsince 04/01/2020
ALLISON, TAMMYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/21/2024
ALLEN, SEANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/09/2023
BRATTON, LISAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/28/2022
DOMINIQUE, KARIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/12/2021
HATTON, REBECCAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/11/2022
NAFZIGER, JACOBIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2022

CMS files one row per role, so the 24 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$10.3M
Net patient revenuemost recent cost report
-15.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 48%Medicare 9%Other / private 44%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$387per resident / day
operating cost
$11,775per month
≈ monthly operating cost
$336per 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 366290. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-10, 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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