The Good Shepherd Health and Rehabilitation Center
622 Center St, Ashland, OH 44805 · For profit - Corporation · 125 certified beds · (419) 289-3523 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- 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
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- 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 (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 4.8% | 5.3% | 15.4% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 6.4% | 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 | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 2.7% | 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 | 6.7% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 5.8% | 6.1% | 16.1% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 35.7% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.1% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.7% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.8% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.2% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 84.5% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 17.9% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.7% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.61 | 1.73 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.21 | 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.
49.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.1% 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 32 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 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% 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
| 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 | 49.2%CMS range 38.2–61.9 | 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 | 11.6%CMS range 8.0–16.4 | 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 | 53.1% | 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 | 31.2% | 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 | 46.9% | 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 | 97.5% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.5% | 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 | 6.6%CMS range 3.6–12.0 | 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 125 beds and averages 113.2 residents a day — about 91% occupied, or roughly 12 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 4.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.98 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.87 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 5.11 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 1.13 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% is below the national median of 45%.
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2023-11-27 · 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, medical record review, hospital documentation review, resident and staff interview, review of a personnel file, review of a disciplinary action document, review of an investigation, policy review, and review of facility initiated corrective action, the facility failed to ensure appropriate care and assistance was provided to prevent a resident fall. This resulted in actual harm when Resident #104 was transferred by a mechanical (Hoyer) lift using only one staff member to assist, and subsequently fell, causing a facial laceration requiring sutures and a fractured right leg which required hospitalization and surgical intervention. This affected one (#104) of three residents reviewed for falls. The facility census was 113. Findings include: Review of Resident #104's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including but…
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 · E2024-07-18 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on infection control tracking, staff interview, and policy review, the facility failed to follow antibiotic stewardship practices in prescribing antimicrobials. This affected 17 (Resident #6, #7, #9, #21, #27, #40, #51, #55, #69, #57, #70, #73, #76, #78, #83, #101, and #107) of 57 resident entries for antimicrobial treatments initiated in May and June 2024. The facility census was 119. Findings include: Review of infection control tracking for May 2024 revealed there were 32 antimicrobial (antibiotic and antifungal) treatments tracked for the month. The treatments were prescribed from a variety of sources that include from the hospital upon admission, emergency room prescribers, hospice prescribers, and the facility's prescribers. Of the antimicrobial treatments tracked in May 2024, 21 were prescribed by the facility's prescribers. Of the antimicrobial treatments prescribed by the facility's prescribers in May 2024, nine did not meet criteria for use and the antimicrobial was not discontinued. Review of infection control tracking for June 2024 revealed there were 25 total…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-18 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) forms contained all the necessary information. This affected one (#65) of three residents reviewed for beneficiary notices. The facility census was 119. Findings include: Review of Resident #65's medical record revealed an admission date of 02/06/24. Medical diagnoses included cerebrovascular accident (stroke), dementia, type II diabetes mellitus with diabetic neuropathy and a history of falls. Review of the Notice of Medicare Non-Coverage (NOMNC) provided to Resident #65's representative, dated 02/19/24, revealed the resident's skilled services would be ending on 02/21/24. The NOMNC did not list what specific type of skilled service would be ending. Review of the SNF ABN provided to Resident #65's representative, dated 02/19/24, revealed the resident's skilled services were being discontinued as the resident no longer required skilled services. The noticed contained no specific…
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 before2024-07-18 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to implement a splinting program to prevent further decrease in range of motion (ROM). This affected one (#23) of one resident reviewed for ROM. The facility census was 119. Findings include: Review of the medical record for Resident #23 revealed and admission date of 03/05/20. Diagnoses include aphasia, metabolic encephalopathy, contracture of the muscle of multiple sites, unspecified epilepticus, and contracture the right hand. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had severe cognitive impairment and was fully dependent on staff for toileting, eating, and transferring. Review of a therapy note dated 11/30/23 revealed Resident #23 was to have a rolled splint applied to the right hand and a resting splint should be used for the left hand to promote digit extension. The therapy note revealed pictures were printed and instructions were provided for staff. Review of nurse aide…
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 before2024-07-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, policy review, and review of facility incident reports, the facility failed to ensure fall interventions were appropriate and resident-centered, and failed to ensure residents with Wander-guards had current physician orders for the security devices. This affected two (#65 and #45) of six residents reviewed for accidents. The facility census was 119. Findings include: 1. Review of Resident #65's medical record revealed an admission date of [DATE]. Medical diagnoses included cerebrovascular accident (stroke), dementia, type II diabetes mellitus with diabetic neuropathy, and a history of falls Review of Resident #65's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with severely impaired cognition. The resident had no recorded behaviors or rejection of care. The resident was identified to have two or more falls without injury and one fall with a minor injury since the prior assessment. Resident #65 was required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, medical record review, and policy review, the facility failed to ensure residents who required non-invasive mechanical ventilation through the use of a continuous positive airway pressure (CPAP) machine had a physician order in place with specified settings for the machine. This affected two (#09 and #59) of two residents reviewed for respiratory care. The facility census was 119. Findings include: 1. Review of Resident #09's medical record revealed an admission date of 02/24/21. Medical diagnoses included asthma, chronic obstructive pulmonary disease (COPD), and morbid obesity. Review of Resident #09's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had severely impaired cognition and had no recorded behaviors or rejection of care. Review of Resident #09's physician order dated 01/04/23 revealed the resident was to have a CPAP machine that was to be applied per home settings nightly at bedtime and as needed. The order did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-18 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, and staff interview, the facility failed to provide dental care in a timely manner. This affected one (#28) of one residents reviewed for dental care. The facility census was 119. Findings include: Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses that included type II diabetes, anxiety, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. Review of a dental note dated 03/15/24 revealed Resident #28 had the potential need for a consultation with an oral maxillofacial surgeon. Resident #28 potentially had extractions that were surgical in nature. Resident #28 had ankylosed (fusion between tooth/teeth and underlying bony support tissues) teeth that would need to be surgically removed by an oral surgeon. Resident #28 was ordered Peridex (used to treat gum inflammation) twice a day for seven days and amoxicillin (antibiotic) 500 milligrams every six hours. 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.
- Potential for harm · D2024-07-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and policy review, the facility failed to use the proper cleaning chemicals were utilized in a resident room with isolation precautions. This affected one (#365) of one residents in contact isolation. The facility census was 119. Findings include: Review of the medical record revealed Resident #365 was admitted on [DATE] with diagnoses that included cellulitis of the left lower leg, Clostridium difficile (C. diff), and dementia. Review of the plan of care dated 07/15/24 revealed Resident #365 had an infection and had the potential for complications related to infection and the treatment of infection. Resident #365 was on the antibiotic vancomycin for C. diff until 07/21/24. Interventions included to administer medications as ordered and use the appropriate precautions. Observation on 07/16/24 at 12:47 P.M. revealed Resident #365 was sitting on the side of the bed and Housekeeper #556 was mopping the floor in Resident #365's room. Interview on 07/16/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-03-03 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and policy review, the facility failed to remove expired medications from the medications carts and medication storage rooms. This affected three of six medication carts and two of three medication storage rooms. This had the potential to affect all 92 residents residing in the facility. Findings include: Observation of Windsor medication cart on 03/01/22 at 7:55 A.M. revealed a bottle of CoQ 10 was found with an expiration date of 01/2022 and a bottle of aspirin 325 milligrams (mg) was located in the cart with an expiration date of 11/2021. Observation of the Windsor [NAME] Hall medication room on 03/01/22 at 8:22 A.M. revealed the following medications expired: Melatonin (sleep aid) 3.0 mg expired 10/2021, Loperamide (anti-diarrhea) 2.0 mg expired 11/2021, B6 vitamins 100 mg expired 11/2021, Geri Dry diphenhydramine (antihistamine) expired 11/2021, and cetirizine hydrochloride (antihistamine) 10 mg which had expired on 07/2021. Observation of the [NAME] hall cart 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 · D2022-03-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interviews, resident interviews, and review of the facility's policy, the facility failed to ensure the residents were assisted with showers routinely and timely as scheduled. This affected two (Residents #27 and #65) of three residents reviewed for bathing. The facility identified all 92 residents required assistance or were dependent on staff for assistance with bathing. The facility census was 92. Findings include: 1. Review of Resident #27's medical record revealed an admission date of 10/16/18. Diagnoses included tremors, congestive heart failure, asthma, and chronic kidney disease. Review of Resident #27's quarterly Minimum Data Set (MDS) assessment, dated 12/21/21, revealed the resident had a high cognitive function. Resident #27 required a one person physical assist with hygiene and was a total dependence on staff for bathing. Review of Resident #27's shower schedule revealed the resident was to have a bath every Monday and Friday. Review of Resident #27's shower documentation electronic records revealed she received a shower/bath on Wednesday…
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 · D2022-03-03 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility's policy, observation, record review and resident and staff interview, the facility failed to provide adequate activities for Resident #9. This affected one (Resident #9) of two residents reviewed for activities. The facility census was 92. Findings include: Review of Resident #9's medical record revealed an initial admission date of 01/09/21. Diagnoses included anxiety, depression, and obstructive sleep apnea. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 11/24/21, revealed Resident #9 had intact cognition. Resident #9 was totally dependent on staff for bed mobility, transfers, toileting, and personal hygiene. Resident #9 considered doing things with groups of people to be somewhat important and participating in her favorite activities to be very important. Review of the plan of care, dated 10/16/21, revealed Resident #9 had the potential for alteration in scheduled/self-initiated events. Interventions included encouraging the resident to participate in activities, offering invites and encouragement, and providing assistance 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.
Show the remaining 16 citations
- Potential for harm · D2022-03-03 · 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 record review, observation, staff interview, and review of a nursing manual, the facility failed to ensure a midline catheter's placement per nursing standards. This affected one (Resident #65) observed for intravenous medication administration. The facility identified one resident on intravenous therapy. The facility census was 93. Findings include: Review of Resident #65's medical records revealed an admission date of 11/09/20. Diagnoses included a bacterial infections to the right ankle and foot. Review of Resident #65's physician's order, dated 02/22/22, revealed an order to flush the midline with 10 milliliters (ml) of normal saline before and after each use every 12 hours. Observation with Licensed Practical Nurse (LPN) #134 on 03/03/22 at 9:22 A.M. revealed LPN #134 completed the physician ordered flush on Resident #65's midline intravenous access. LPN #134 was observed cleaning the access and placing a 10 ml syringe of normal saline to the access site. LPN #134 pushed the solution directly into…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-04-05 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, Minimum Data Set (MDS) Resident Assessment Instrument manual review and staff interviews, the facility failed to ensure MDS assessments were accurate. This affected four (#6, #86, #56, #98) of 26 resident MDS assessments reviewed. The facility census was 118. Findings include: 1. Review of Resident #6's medical record review revealed an admission date of 08/16/16, with diagnoses including: Alzheimer's disease, dementia, dysphagia, difficulty walking, dementia, anxiety and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severe cognitive impairment and a weight gain. Review of the monthly weight report revealed Resident #6 weighed 94 pounds on 02/01/19. Resident #6 weighed 89 pounds on 03/01/19 indicating a 5.32% weight loss in thirty days. Review of a health status progress note dated 03/01/19 at 4:12 P.M., revealed Resident #6 had a significant weight loss of 5.3 percent in the past 30 days. Interview on 04/05/19 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.
- Potential for harm · Ecited before2019-04-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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, facility policy review, resident and staff interviews, the facility failed to implement interventions to prevent falls. This affected one (#88) of three sampled residents reviewed for accidents. The facility also failed to ensure staff did not leave medications, unattended in one resident's room (Resident #98). This could potentially affect three (#57, #67, and #77) residents identified by the facility as confused and independently mobile. The facility census was 118. Findings include 1. Review of Resident #88's medical record revealed an admission date of 01/28/19, with diagnoses including: throat mass, diarrhea, difficulty swallowing, throat cancer, and dementia. Review of the admission assessment (MDS) dated [DATE] identified Resident #88 was high risk for falling and a written plan of care was required. The assessment further identified Resident #88 required extensive assistance of two persons for transfers. Resident #88's medical record identified while in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-05 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 observations, medical record review, policy review and staff interviews, the facility failed to ensure a urinary catheter drainage bag was appropriately covered. This affected one of one (#45) of one residents reviewed for dignity. The facility identified nine residents with urinary catheters. The facility census was 118. Findings include Review of Resident #45's medical record revealed an admission date of 09/11/18 and diagnoses included: sepsis, a pressure ulcer of the sacral region, osteomyelitis, chronic kidney disease stage three, anemia, respiratory failure, hypotension and quadriplegia. Observation on 04/02/19 at 11:06 A.M. and on 04/03/19 at 11:34 A.M., revealed Resident #45's urinary catheter drainage bag was not covered. Interview on 04/03/19 at 11:36 A.M., with Licensed Practical Nurse (LPN) #256 verified Resident #45's urinary catheter drainage bag was uncovered. LPN #256 told Resident #45 she would get a cover. Interview on 04/03/19 at 1:42 P.M., with the Assistant Director of Nursing (ADON) #243 revealed urinary catheter drainage bags should be covered. Review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-05 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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, policy review, resident and staff interviews, the facility failed to ensure residents and resident representatives were given an opportunity to participate in the care planning process. This affected two (#12 and #88) of 26 residents reviewed for care plans. The facility census was 118. Findings include: 1. Review of Resident #12's medical record revealed an admission date of 03/30/18, with diagnoses including: Diabetes Mellitus, acute kidney failure, and cerebralvascular disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact. Review of the resident's Interdisciplinary Team Care Conference Summary forms dated 04/10/18, 07/10/18, 10/02/18, and 01/01/19 revealed a documented Care Conference was held for the resident. Multiple staff members signed the form indicating they were in attendance. None of the forms contained the resident or the resident's wife's signatures. Review of the resident's progress notes revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-05 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to notify a resident's physician and family of a significant weight loss. This affected one (#6) of two residents reviewed for nutrition. The facility census was 118. Finding include Record review of Resident #6's medical record revealed an admission date of 08/16/16, with diagnoses including: Alzheimer's disease, dysphagia, difficulty walking, dementia, anxiety and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severe cognitive impairment. Review of the monthly weight report revealed Resident #6 weighed 94 pounds on 02/01/19. Resident #6 weighed 89 pounds on 03/01/19 indicating a 5.32% weight loss in thirty days. Review of a health status progress note dated 03/01/19 at 4:12 P.M., revealed Resident #6 had a significant weight loss of 5.3 percent in the past 30 days. Review of the nurse's progress notes from 03/01/19 through 04/02/19 revealed no documentation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-04-05 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide written notification to residents and resident representatives of emergency transfers to the hospital. This affected three (#98, #101 and #314) of five residents reviewed for discharge. The facility census was 118. Findings include: 1. Review of Resident #314's medical record revealed an admission date of 07/28/16, with a most recent readmission date of 03/26/19. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively impaired. Review of the facility's Resident Transfer Forms for Resident #314 revealed the resident was transferred to an acute care hospital on [DATE], 12/28/18, and 03/21/19. No documentation was available of the facility providing written notification to the resident, the resident's representative, or the State Ombudsman's office of the emergency transfers. 2. Review of Resident #98's medical record revealed an admission date of 09/26/18. The medical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-05 · tag F0625 — isolatedNotify 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, bed hold notification policy and staff interview, the facility failed to provide a medicaid resident with bed hold notice upon transfer to the hospital. This affected one (#101) of five residents reviewed for hospitalization. The facility census was 118. Findings include: Review of Resident #101's medical record revealed an admission date of 01/25/18. The record revealed Resident #101's payer source was medicaid. The record further identified Resident #101 required hospitalization on 01/28/19. The record was silent to any notification of bed hold upon discharge to identify the number of bed hold days Resident #101 had left. Resident #101 was readmitted to the facility on [DATE]. Review of the facility's current admission packet identified bed reserve policy dated 05/26/18, identified the facility follows the state Medicaid plan which reimburses up to 30 days for hospitalization per calendar year. The policy did not contain any need to notify residents upon hospitalization 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.
- Potential for harm · D2019-04-05 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 closed medical record review and staff interview, the facility failed to complete a recapitulation/discharge summary for a resident discharged from the facility. This affected one (#113) of one reviewed for discharge. The facility census was 118. Findings include: Review of Resident #113's closed medical record revealed an admission date of 01/04/19 and discharged to home on [DATE]. Diagnoses included: congestive heart failure, admitted with right femur and right radius fractures and patella fracture, Parkinson's disease and macular degeneration. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #113 was cognitively intact with no noted behaviors. Review of Section Q - Participation in Assessment and Goal Setting revealed the resident participated in the assessment and goal setting and expected to be discharged to the community. Review of the progress notes dated 01/09/19 revealed the resident was discharged home with Palliative care. Further review of the complete medical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-05 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure 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
Based on medical record review and staff interview, the facility failed to initiate restorative programs for one (#88) of 26 sampled residents. The facility census was 118. Findings include: Review of Resident #88's medical record revealed an admission date of 01/28/19, following a hospitalization. The record identified prior to admission Resident #88 resided at home with his daughter. Review of the discharge plan of care, dated 03/20/19 identified Resident #88 plans on returning home following rehabilitation at the facility. Review of the Therapy Restorative Recommendation dated 03/23/19, revealed orders for a restorative walking and dressing/grooming programs. Further review of the medical record revealed as of 04/04/19, there was no documentation of the restorative programs being initiated. Interview with Registered Nurse (RN) #130, on 04/04/19 at 1:44 P.M., revealed she was in charge of the restorative programs at the facility. The interview identified when residents are discharged from therapy, they recommend restorative programs. RN #130 identified therapy completes a Therapy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-04-05 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review, staff and resident interviews, the facility failed to provide restorative range of motion services. This affected two (#9 and #88) of two residents reviewed for restorative. The facility census was 118. Findings include 1. Review Resident #9's medical record revealed an admission date on 10/08/14. Diagnoses included atherosclerosis of native arteries of the right leg with ulceration of the heel and midfoot, peripheral vascular disease, hypertension and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had intact cognition. Review of a physician order dated 01/10/19 revealed Resident #9 was ordered seated active range of motion (AROM) to the bilateral upper extremities for 15 minutes a day, six to seven days per week. Review of restorative task documentation from 03/05/19 through 04/03/19, revealed Resident #9 was not offered AROM on 18 days. Resident #9 received AROM on 03/25/19, 03/26/19, 03/28/19,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-05 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record, facility policy and staff interview, the facility failed to administer physician ordered tube feeding in accordance with the orders. This affected one (#2) random resident observed of 13 residents identified receiving enteral tube feeding. The facility census was 118. Findings include: Review of Resident #2's medical record revealed re-admission date of 01/06/19, with medical diagnosis including: dysphasia, respiratory failure and tracheotomy. Review of the physician orders for April 2019 identified Resident #2 should be receiving enteral tube feeding (Isosource 1.5) 40 milliliter/hour (ml/hour) via peg tube around the clock. Observation of Resident #2 on 04/04/19 at 8:30 A.M., during her medication administration time, revealed Resident #2 was noted to be receiving enteral tube feeding at that time of Isosurce 1.5 at a rate of 60 ml/hour. The observation identified the bag of solution hanging did not include the rate at which the feeding should be infused. Registered Nurse (RN) #233 was observed to place the tube feeding on hold, administer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, family and staff interviews, the facility failed to ensure a resident receiving an anti-psychotic medication had a justified medical diagnosis to support the use. This affected one (#88) of five residents reviewed for medications. The facility census was 118. Findings include 1. Review of Resident #88's medical record revealed an admission date of 01/28/19, with diagnoses including: throat mass, diarrhea, difficulty swallowing, throat cancer, and dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], identified Resident #88 was receiving an anti-psychotic medication (Seroquel 200 mg) and identified no behaviors or mood issues. The assessment identified Resident #88 had a BIMS (brief interview for mental status) score of 11, which identifies mildly impaired cognition. Further review of the record identified no targeted behaviors Resident #88 was being evaluated for. The medical record identified no psychiatric history and or targeted behaviors Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-05 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview the facility failed to ensure necessary room repairs were completed. This affected three of 32 resident rooms observed. Residents #84, #87, #29, #6, #172, and #49 resided in these rooms. The facility census was 118. Findings include 1. Observation on 04/03/19 at 2:55 P.M. in the shared bathroom of Resident #84 and Resident #87 revealed there was no mopboard. The drywall was exposed and damaged at the base of the bathroom walls. Interview on 04/03/19 at 2:55 P.M., with the Director of Environmental Services (DES) #300 revealed the damage was caused by a water leak in another room in January. DES #300 revealed it was an oversight the bathroom mopboard had not been replaced. 2. Observations on 04/03/19 at 2:55 P.M. and 3:02 P.M., revealed water stained ceiling tiles in two bathrooms shared by four residents (#6, #29, #172, #49). Interviews on 04/03/19 at 2:55 P.M. and 3:02 P.M. with the Director of Environmental Services (DES) #300 confirmed the ceiling tiles in the two bathrooms were stained. DES #300 stated staff should report rooms in need 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.
- No harm found · C2022-03-03 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, policy review, and staff interview, the facility failed to ensure posted nursing staff information was updated timely and accurate. This had the potential to affect all 92 residents residing in the facility. Findings include: Observation of the posted nursing staff information on 02/28/22 at 8:12 A.M. and at 10:50 A.M. revealed the posted nursing staff information was from 02/25/22 and contained the staff numbers for the 7:00 A.M. to 3:00 P.M. shift. Observation of the posted nursing staff information on 03/02/22 at 7:41 A.M. and at 9:13 A.M. revealed the posted nursing staff information was from 03/01/22 and contained the staffing numbers for the 7:00 A.M. to 3:00 P.M. shift. Interview on 03/02/22 at 10:20 A.M. with the Licensed Practical Nurse (LPN) #265 revealed the nurse supervisors were to update and post nursing staff information each shift. Interview on 03/02/22 at 11:16 A.M. with the Assisted Director of Nursing (ADON) #156 verified nurse supervisors were to update and post nurse staff information each shift. The ADON #156 further verified the posted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2022-03-03 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the representative of the Office of the State Long-Term Care Ombudsman was notified of the resident's transfers to the hospital. This affected two (Resident #60 and #334) of two residents reviewed for hospitalization. The facility census was 92. Findings include: 1. Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included aphasia following cerebral vascular disease, syncope and collapse, and hemiplegia and hemiparesis. Review of the nursing progress notes revealed Resident #60 was sent out and subsequently admitted to a local hospital on [DATE]. Review of both the electronic and hard charts for Resident #60 revealed there was no evidence the representative of the Office of the State Long-Term Care Ombudsman was notified of Resident #60's transfers to the hospital on [DATE]. Interview on 03/01/22 at 3:00 P.M. with the Administrator verified that the facility did not notify 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LUTHERAN SOCIAL SERVICES OF CENTRAL OHIO, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 11/29/1999 |
| DUNN, ROBERT | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| KENDALL, EARL | Individual | CORPORATE DIRECTOR | — | since 02/01/2019 |
| KERR, RONALD | Individual | CORPORATE DIRECTOR | — | since 08/01/2022 |
| MANSER, MARLENE | Individual | CORPORATE DIRECTOR | — | since 02/01/2023 |
| MARTIN-TERRY, WANDA | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| MCCLENDON, AARON | Individual | CORPORATE DIRECTOR | — | since 10/01/2020 |
| MEEK, VIOLET | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| MESLOW, ANDREW | Individual | CORPORATE DIRECTOR | — | since 10/01/2019 |
| MITCHELL, DEBORAH | Individual | CORPORATE DIRECTOR | — | since 03/01/2020 |
| PRILLERMAN, SHEILA | Individual | CORPORATE DIRECTOR | — | since 02/01/2023 |
| RIGGINS, BRANDON | Individual | CORPORATE DIRECTOR | — | since 10/01/2020 |
| STEINBRENNER, ADAM | Individual | CORPORATE DIRECTOR | — | since 10/01/2019 |
| SUITER, BRIAN | Individual | CORPORATE DIRECTOR | — | since 10/01/2020 |
| TUNIS PHEISTER, ERIN | Individual | CORPORATE DIRECTOR | — | since 08/01/2024 |
| FRATIANNE, JULIA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/07/2025 |
| LUSTIG, RACHEL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/15/2023 |
| MILLER, KIMBERLY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/11/2024 |
| ABRAHAM, JOSEPH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2006 |
| APPLEGATE, ALICIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/09/2020 |
| BOGNER, KRISTY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/27/2020 |
| DUBBE, HEATHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/25/2007 |
| KERR, SARAH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2001 |
| MCQUATE, ERIC | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/04/2011 |
| SAVAGE, THERESSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/22/2019 |
| SMITH, ANNA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/28/2019 |
| SPRING, LORI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/08/2021 |
| STUCKY, ERIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/26/2022 |
| TAVALLAEE, MEHRDAD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2008 |
| UHLER, JULIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/14/2004 |
| WHITE, LORIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/06/1992 |
| WOLVERTON, CHAD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/20/2017 |
| ENHANCE THERAPIES HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| HUNTINGTON | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| PLANTE & MORAN PLLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| SQUARED BUSINESS SOLUTIONS, LLC | Organization | ADP OF THE SNF | — | since 01/13/2020 |
CMS files one row per role, so the 57 rows in the source record cover these 36 parties — each is shown once here with every role it holds. Nothing is omitted.
5 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.
This home reported $470K 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 2024. 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, FY2024). 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 365093. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-18, 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 →
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