Crystal Care Center Of Ashland
1251 East Main Street, Ashland, OH 44805 · For profit - Limited Liability company · 72 certified beds · (419) 281-9595 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has 1 actual-harm citation
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- 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
- the CMS record shows $17,686 in federal fines (most recent 2025-08-06)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 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
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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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.2% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 7.2% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.5% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 12.4% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.9% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 4.3% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 27.9% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.3% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 18.9% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.4% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.4% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.6% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 19.5% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.56 | 1.73 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.16 | 1.80 | 1.80 | 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.
48.6% 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 51 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 64.5% 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 31 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 48.6%CMS range 34.9–59.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.0%CMS range 6.3–13.3 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 64.5% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 67.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 58.1% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not 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 stay | 2.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 4.1–11.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.88 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 72 beds and averages 61.0 residents a day — about 85% occupied, or roughly 11 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 2.93 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.73 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.85 hrs/resident/day on weekends vs 2.97 on weekdays — 4% thinner on weekends. RN hours go from 0.39 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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 12 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · G2025-08-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interview, closed medical record review, facility policy review, review of an Emergency Medical Services (EMS) run report, and hospital records, the facility failed to ensure Resident #60 was transferred and weighed in a manner consistent with his plan of care. This resulted in Actual Harm on [DATE] at approximately 9:00 A.M. when Resident #60 was weighed while using a Hoyer (mechanical) lift by Certified Nursing Assistants (CNA) #150 and #152. Resident #60 raised himself up in his electric lift chair, stood up with the assistance of his front wheeled walker, and a Hoyer lift sling was placed underneath him. Resident #60 was then raised into the air by two staff members in the Hoyer lift, where Resident #60 weighed 438 pounds. After the weight was obtained, Resident #60's lift chair was stuck in an upright position, so a decision was made by the two CNAs to place…
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.
- Actual harm · G2025-05-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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, resident interview, staff interview, Nurse Practitioner (NP) interview, review of hospital records, and review of facility policy, the facility failed to adequately monitor Resident #271's cellulitis (potentially serious bacterial skin infection), failed to timely identify a change in condition, and further failed to notify the physician of the resident's decline. This resulted in actual harm for Resident #271 on 03/29/25 when the facility failed to adequately monitor the resident's right lower extremity cellulitis to identify a worsening of the condition and, therefore, did not notify the physician of the decline. Resident #271's family member intervened and requested the facility transfer the resident to the hospital for further evaluation and treatment. Subsequently, Resident #271 was admitted to the hospital and treated with intravenous (IV) antibiotics due to a deterioration of the condition. Additionally, the facility failed to provide interventions for constipation 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.
- Potential for harm · Ecited before2026-04-23 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview and review of the manufacturer instructions for the facility glucometers, the facility failed to ensure staff maintained proper infection control practices while using glucometers. This affected two (Residents #12 and #41) of two residents blood sugar assessments observed and had the potential to affect an additional seven (Residents #3, #5, #24, #40, #41, #43, #44 and #58) identified by the facility as also receiving blood sugar monitoring via glucometer. The facility census was 58.Findings include:1. Record review for Resident #12 revealed an admission date of 10/29/25. Diagnoses included type two diabetes mellitus with diabetic chronic kidney disease and muscle weakness.Review of the care plan dated 10/29/25 revealed Resident #12 had potential risk for hyper/hypoglycemia due to diagnosis of diabetes. Interventions included obtaining blood sugar levels as ordered.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-23 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a safe discharge for Resident #62. This affected one (Resident #62) of three residents reviewed for planned discharges. The facility census was 58.Findings include:Closed record review for Resident #62 revealed an admission date of 06/23/25 and a discharge date of 12/05/25. Diagnoses included osteomyelitis, sacral spina bifida, paraplegia, muscle weakness, cauda equina syndrome (roots of nerves form a bundle in the lowest part of the spinal column), chronic myeloproliferative disease (rare blood cancers), chronic kidney disease stage three, peripheral vascular disease, diplegia of upper limbs (a type of cerebral palsy the muscles in the arms and hands are weak or paralyzed making it difficult to perform daily activities), chronic myeloid leukemia, Arnold Chiari Syndrome (structural problem affecting the brain which can affect function and lead to various neurological challenges) with spina bifida, chronic angle closure glaucoma bilateral, type…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interviews, facility policy review, and review of the 2025 International Pressure Injury Guidelines, the facility did not follow appropriate infection control practices during wound care and failed to provide or offer an appropriate pressure reducing mattress to support healing of a pressure ulcer. This failure affected one resident (Resident #26) of three residents reviewed for wound care. The facility census was 58.Findings include: Record review for Resident #26 showed admission on [DATE], discharge on [DATE], readmission on [DATE], discharge on [DATE], and readmission on [DATE]. Diagnoses included a Stage IV pressure ulcer and muscle weakness. A Stage IV ulcer involves full thickness tissue loss with exposed bone, tendon, or muscle, and may include slough, undermining, or tunneling.Review of the care plan dated 07/25/25 indicated an actual skin impairment to the sacrum related to pressure. Interventions included initiating wound treatment, continuing treatment as ordered,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-23 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and review of the insulin pen instruction manual, the facility failed to administer insulin to Resident #12 per the physician order. This affected one (Resident #12) of two residents observed for insulin administration. The facility census was 58.Findings include:Record review for Resident #12 revealed an admission date of 10/29/25. Diagnoses included type two diabetes mellitus with diabetic chronic kidney disease and muscle weakness. Review of the care plan dated 10/29/25 revealed Resident #12 had potential risk for hyper/hypoglycemia due to diagnosis of diabetes. Interventions included administering medications per physician's order.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 was mildly cognitively impaired, required assistance with activities of daily living, and received hypoglycemic medication (including insulin) and insulin injections daily. Review of the physician order dated 04/20/26 revealed an order 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.
- Potential for harm · F2025-05-06 · tag F0725 — failed to have enough nursing staff — widespreadProvide 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
Based on resident interview, staff interview, review of the Facility Assessment (FA) and review of staffing reports, the facility failed to have sufficient staff to meet resident needs as identified in the FA. This had the potential to affect all 59 residents of the facility. The facility census was 59. Findings include: Interview with Resident #30 on 04/28/25 at 9:34 A.M. revealed the facility was extremely short staffed and her call light went unanswered on multiple occasions, which resulted in her urinating on herself in bed. Resident #30 revealed call lights were often unanswered within 30 minutes on second and third shifts. Interview with Resident #35 on 04/28/25 at 10:04 A.M. revealed Certified Nursing Assistants (CNAs) took a long time to answer call lights. Resident #35 stated staff instruct her to stay in bed until assistance arrived, but no one comes. Interview with Resident #269 on 04/28/25 at 10:36 A.M. revealed care was not provided timely and she had taken herself to the bathroom, even though she was directed to wait for staff assistance. Interview with Resident #18 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.
- Potential for harm · F2025-05-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview and review of the facility policy, the facility failed to maintain a clean and sanitary kitchen and further failed to ensure food items were not stored directly on the floor. This had the potential to affect all 59 residents who received meals from the facility kitchen. The facility census was 59. Findings include: Observations on 04/28/25, beginning at approximately 8:15 A.M., revealed the following: • The dry storage area, located in the main kitchen, revealed there were three crates of onions stacked and stored directly on the floor. • The wall behind the dishwashing machine had an unknown black substance, which went from mid-wall down to the floor. • There was buildup and debris under a metal table located in the kitchen. • There was buildup and debris located against a wall and behind a refrigerator in the kitchen. A concurrent interview with Dietary Manager #750 verified the above findings. DM #750 reported the black substance behind the dishwashing machine was mold. Review of the facility policy titled, Food Safety Requirements, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-06 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, and policy review, the facility failed to maintain a comfortable, clean, sanitary, and homelike environment that was in good repair. This affected four (#40, #30, #48 and #22) of four residents reviewed for the environment with the potential to affect and additional 23 residents (#3, #8, #10, #16, #17, #20, #24, #26, #27, #28, #34, #41, #42, #43, #47, #54, #57, #59, #319, #320, #321, #322, #323) residents who resided on the 300-unit. The facility census was 59. Findings include: 1. Observation on 04/28/25 at approximately 10:10 A.M. revealed a door was located at the far end of the 300-hall, past the nursing station. There was a gap between the bottom of the door and the door frame, through which the outside could be seen. Interview on 04/28/25 at approximately 10:15 A.M. with Resident #40 revealed the resident could often feel the elements of the weather because of the gap between the door and the doorframe. Resident #40 reported she could feel the heat and cold air coming in, she worried about insects getting in, and it…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-06 · tag F0573 — isolatedLet each resident or the resident's legal representative access or purchase copies of all the resident's records.
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 electronic communications (e-mail), staff interview and review of facility policy, the facility failed to ensure a request for medical records was addressed timely. This affected one (#270) of one resident reviewed for medical record requests. The facility census was 59. Findings include: Review of the medical record for Resident #270 revealed an admission date of 01/21/25 and a discharge date of 03/21/25. Diagnoses include altered mental status, psychosis, encephalopathy, anxiety, restlessness and agitation, depression, sepsis, hypertension, and a history of cerebral infarction. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of an e-mail, dated 03/07/25 at 4:08 P.M., revealed Resident #270's family member requested the resident's medical records from the facility. Further review of an e-mail dated 03/14/25 at 2:15 P.M., revealed Resident #270's family member sent another email…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, medical record review and review of facility policy, the facility failed to ensure wound care recommendations for an alternating air/low air loss mattress were implemented to prevent the development of pressure ulcers. This affected on (#53) of three residents reviewed for pressure ulcers. The facility census was 59. Findings included: Review of Resident #53's medical record revealed an admission date of 10/07/24. Diagnoses included lymphedema, chronic kidney disease, and obstructive uropathy. Review of Resident #53's quarterly Minimum Data Set (MDS) assessment, dated 01/14/25, revealed the resident had an intact cognition. The resident required substantial/maximal staff assistance to roll left and right in bed and had impairments on both sides of his lower extremities. Review of Resident #53's care plan revealed he was at risk for alteration in skin integrity. Interventions included a pressure reducing mattress on his bed to promote comfort and prevent skin breakdown. Review of Resident #53's Braden Scale (assessment 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.
- Potential for harm · Dcited before2025-05-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
2. Review of the medical record for Resident #48 revealed an admission date of 02/02/24. Diagnoses included type II diabetes mellitus and obstructive and reflux uropathy. Review of the quarterly MDS assessment, dated dated 03/31/25, revealed Resident #48 was cognitively intact and had an indwelling urinary catheter. Review of a physician order dated 09/30/24 revealed Resident #48 had an order for indwelling urinary catheter care every shift. Review of the Treatment Administration Record (TAR) for April 2025 revealed Resident #48's catheter care was not documented as provided on the 6:00 A.M. to 6:00 P.M. shift on 04/04/25, 04/06/25, 04/09/25, 04/10/25, 04/19/25, and 04/20/25. Further review revealed no evidence the care was provided on the 6:00 P.M. to 6:00 A.M. on 04/23/25. Interview on 04/30/25 at 9:18 A.M. with Registered Nurse (RN) #345 confirmed catheter care was not documented as completed for Resident #48 on the 6:00 A.M. to 6:00 P.M. shift on 04/04/25, 04/06/25, 04/09/25, 04/10/25, 04/19/25, and 04/20/25 and on the 6:00 P.M. to 6:00 A.M. shift on 04/23/25. 3. 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.
Show the remaining 11 citations
- Potential for harm · D2025-05-06 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, visitor interview, and review of facility policies, the facility failed to obtain physician orders to ensure a percutaneous endoscopic gastrostomy (PEG) tube was monitored and cared for appropriately. This affected one (#28) of one resident reviewed fur tube feedings. The facility census was 59. Findings include: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included dysphagia, muscle weakness, anemia, ileus, and hypertension. Review of the admission Minimum Data Set (MDS) assessment, dated 01/23/25, revealed Resident #28 was severely cognitively impaired and had a feeding tube. Review of the plan of care, dated 01/21/25, revealed Resident #28 had the potential for alteration in skin integrity. Interventions included cleansing the area around the PEG tube site as ordered and as needed, apply dressing, inspect the skin around the PEG tube daily for redness/drainage/breakdown, and observe the PEG…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-06 · tag F0694 — isolatedProvide 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, staff interview and review of the facility policy, the facility failed to ensure central lines were cared for in accordance with professional standards of practice. This affected one (#323) of one resident reviewed for intravenous (IV) therapy. The facility census was 59. Findings include: Review of the medical record revealed Resident #323 was admitted to the facility on [DATE]. Diagnoses included atherosclerosis of native arteries of extremities with gangrene, hypertension, end stage renal disease, type II diabetes mellitus, and hyperkalemia. Review of the admission Minimum Data Set (MDS) assessment, dated 04/09/25, revealed Resident #323 was cognitively intact. The resident had a central line. Review of the plan of care dated 04/18/25 revealed Resident #323 had potential for complications related to use of IV medications and/or IV fluids. Interventions included changing the dressing to the IV site as ordered and per facility policy, checking for signs and symptoms…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-06 · tag F0697 — failed to manage pain — isolatedProvide 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 interview, staff interview and review of facility policy, the facility failed to ensure resident pain was effectively managed. This affected one (#269) of one resident reviewed for pain management. The facility census was 59. Findings include: Review of the medical record for Resident #269 revealed an admission date of 04/25/25. Diagnoses included fracture of the left lower leg, chronic pain, and anxiety. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #269 was cognitively intact. Review of physician orders dated 04/25/25 revealed Resident #269 had orders for Tylenol 325 milligrams (mg) by mouth every four hours as needed for pain and oxycodone-acetaminophen 5-325 mg, give one tablet by mouth every six hours as needed for pain. Review of the Medication Administration Record (MAR) for April 2025 , dated 04/2025 revealed on 04/26/25 at 3:00 A.M., Licensed Practical Nurse (LPN) #360 administered Tylenol 650 mg to Resident #269 for a pain level…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-06 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 pharmacy recommendations, staff interview and review of facility policy, the facility failed to ensure pharmacy recommendations were reviewed by the physician timely. This affected one (#3) of five residents reviewed for unnecessary medications. The facility census was 59. Findings include: Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included asthma, type II diabetes mellitus, schizoaffective disorder, depression, anxiety disorder, schizophrenia, and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/30/25, revealed Resident #3 was cognitively intact. The resident received antipsychotic and antidepressant medication. Review of Resident #3's physician orders revealed an order dated 01/30/24 for Famotidine (acid reducer) 40 milligram (mg) oral tablet, give one tablet by mouth at bedtime for ulcer. The resident also had an order dated 01/13/25 through 04/05/25 for Hydroxyzine (antihistamine)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-06 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, staff interview and review of the facility policy, the facility failed to properly store medications in a safe manner. This affected one (#21) of one resident reviewed for for medication storage. The facility census was 59. Findings include: Review of the medical record for Resident #21 revealed an admission date of 05/19/23. Diagnoses included neuromuscular dysfunction of the bladder, benign prostatic hyperplasia, and unspecified pain. Review of the quarterly Minimum Data Set (MDS) assessment, dated, revealed Resident #21 was cognitively intact. Review of the physician orders revealed an order dated for Xtampza ER (extended release oxycodone) 12 hour 18 milligram (mg), give one capsule by mouth two times a day for pain. Further review revealed no physician order for Resident #21 to self-administer medications or for medications to be left at the bedside. Observation on 05/01/25 at 7:47 A.M. revealed Resident #21 sitting in his wheelchair, reclined back with his eyes closed. Further observation revealed a medication cup with one unknown…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-06 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, staff interview, medical record review, review of the Centers for Disease Control and Prevention (CDC) guidance and review of facility policy, the facility failed to ensure receptacles for contaminated personal protective equipment (PPE) were appropriately placed to prevent the transmission of pathogens. This affected one (#320) reviewed for urinary tract infections and medication administration. The facility census was 59. Findings included: Review of Resident #320's medical record revealed an admission date of 04/10/25. Diagnoses included methicillin susceptible Staphylococcus aureus (MSSA - infection caused by staph bacteria) infection of the left hip joint, alcoholism, and hepatitis C. Review of Resident #320's care plan revealed she required isolation/quarantine due to MSSA of a wound. Interventions included isolation/quarantine precautions would be maintained by staff during acute infection period. Review of Resident #320's physician orders revealed an order dated 04/11/25 for Cefazolin (antibiotic) two milligrams (mg) per 100 milliliters (ml) over 30…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to ensure physician's orders were followed timely to change the resident's Foley catheter. This affected one (#60) of three residents reviewed for Foley catheter. The facility census was 65. Findings include: Review of the medical record for Resident #60 revealed an admission date of 11/17/23, with diagnoses including absence of left leg below the knee, diabetes mellitus, and obstructive with reflux uropathy (disorder where urine can't flow normally through the urinary tract due to an obstruction). Review of the written physician's progress note and written order dated 12/06/23, from Resident #60's urologist, revealed she had the same Foley in place from November 2023, when she was hospitalized . He had ordered for the facility staff to exchange the catheter on 12/06/23. Review of the Treatment Administration Record (TAR) for Resident #60 for December 2023 and January 2024, revealed nursing staff had not changed her catheter out as ordered on 12/06/23 until 01/02/24. Review of Resident #60's physician's order dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-09-14 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 medical record review, observation, staff interview, review of the county positivity rate, review of the Centers for Disease Control (CDC) online resources, and policy review, the facility failed to ensure staff sanitized their eye protection upon leaving the room of residents identified to be on transmission-based precautions. This had the potential to affect all residents residing in the facility. The facility census was 57. Findings include: 1. Observation on 09/06/22 at 4:30 P.M. of the designated COVID-19 unit entrance, revealed a set of double-doors with signage instructing those entering to see the nurse prior to entering. Additional signage was posted regarding donning and doffing procedures for personal protective equipment (PPE). One three-drawer cart was located near the entrance, which contained blue disposable gowns, gloves, medical-surgical masks, and hand sanitizer. No disinfectant wipes or spray was located on or near the cart. Interview on 09/06/22 at 4:35 P.M., with Licensed Practical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-09-14 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review the facility failed to ensure expired over the counter medication was removed from the medication cart and the medication storage room. This affected one medication cart and one medication storage room out of one medication cart and medication storage room observed. The facility had a total of two medication carts and two medication storage rooms. The facility identified four residents (#10, #05, #03, and #48) who were ordered the expired medications in the medication cart and the medication storage room. The facility census was 57. Findings include: Observation on 09/07/22 at 7:08 A.M. of the medication cart during medication administration on the 100 hall revealed aspirin 325 milligrams (mg) had an expiration date of 06/22. Aspirin was not administered to Resident #03 at this time. Interview on 09/07/22 at 7:10 A.M., with Licensed Practical Nurse (LPN) #485 verified the aspirin 325 mg had an expiration date of 06/22. LPN #485 said it should have been removed from the cart. Observation on 09/07/22 at 7:24 A.M. of the medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-09-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the hospital after visit summary, and policy review, the facility failed to ensure timely treatments were in place when a resident was admitted with a deep tissue injury. This affected one resident (#203) out of three residents reviewed for pressure ulcers. The facility census was 57. Findings include: Review of medical record for Resident #203 revealed an admission date of 08/11/22. Diagnoses included displaced subtrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, cognitive communication deficit, dysphagia, chronic kidney disease stage III hyperlipidemia, Alzheimer's disease, and aphasia. Review of the hospital after visit summary dated 08/11/22 revealed no indication of skin breakdown to Resident #203's left heel nor orders for treatment for skin breakdown upon discharge. Review of the admission assessment dated [DATE] revealed Resident #203 had a suspected deep tissue injury of the left heel measuring…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-14 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to serve food at a safe and palatable temperature for resident satisfaction. This affected two residents (#35 and #40) out of six residents reviewed for meal service concerns. The facility census was 57. Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 06/04/21. Diagnoses included spinal stenosis, thoracic region, affective mood disorder, diabetes mellitus type II with diabetic neuropathy, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #35 had intact cognition. Interview on 09/06/22 at 11:12 A.M., with Resident #35 revealed the food was not always hot enough, foods were repeated too often, and had not always looked appealing. 2. Review of the medical record for Resident #40 revealed an admission date of 08/03/22. Diagnoses included COVID-19, type two diabetes, chronic kidney disease stage four, hypertension, osteoarthritis, peripheral…
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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$17,686 in federal fines across 1 penalty.
- $17,686 — penalty dated 2025-08-06
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to EMBASSY HEALTHCARE — 33 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.4 | -1.4 vs chain |
| Health inspection | 2 of 5 | 2.1 | -0.1 vs chain |
| Staffing | 1 of 5 | 1.8 | -0.8 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 32 homes this chain runs (chain average 2.4★, 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 / manager | Type | Role | Since |
|---|---|---|---|
| REPCHICK, GEORGE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2020 |
| EMBASSY HEALTHCARE MANAGEMENT INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2020 |
| CURRAN, DAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| HANDLER, AARON | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2020 |
| HERITAGE EMPLOYMENT SERVICES, LLC | Organization | ADP OF THE SNF | since 01/01/2020 |
CMS files one row per role, so the 9 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 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.
About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $315K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366239. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.