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Woods On French Creek Nursing & Rehab Center The

37845 Colorado Avenue, Avon, OH 44011 · For profit - Corporation · 74 certified beds · (440) 695-1400 Medicare & Medicaid certified

Call the home — (440) 695-1400 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609) — most recent Dec 2018Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations CMS recorded as corrected before the inspection ended (past non-compliance)$26,685 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 2 serious findings 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $26,685 in federal fines (most recent 2025-11-06)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (2/5)
  • its last standard health inspection was over 3 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
32818 Walker Rd Ste E7 · (440) 879-2970 · Call to confirm hours
Pharmacy
38530 Chester Rd Ste 400 · (440) 934-3100 · Call to confirm hours
Grocery
Marc's1.4 mi
35901 Detroit Rd · (440) 937-2555 · Call to confirm hours
Park
2155 Eaton Dr · (440) 937-6106 · Typically dawn to dusk
Place of worship
37300 Detroit Rd · (440) 397-5564

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 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 held steady at 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.7%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight3.6%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms64.7%30.1%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.4%3.2%3.3%better
Long-stay residents whose ability to walk worsened7.3%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication27.1%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine98.3%94.5%95.3%typical
Long-stay residents with pressure ulcers1.7%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control24.1%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.7%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine51.2%75.6%79.4%worse
Short-stay residents rehospitalized after admission36.0%24.9%22.6%worse
Short-stay residents with an outpatient ER visit13.6%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.831.731.67typical
Long-stay outpatient ER visits per 1,000 resident days1.051.801.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

50.5% 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 125 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.5%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
86.1%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 86.1% 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 79 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 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.5%CMS range 41.9–58.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 6.9–14.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge86.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge67.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge88.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting33.3%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 3.8–11.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.881.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.60
RN hours/ resident / day
0.65
LPN hours/ resident / day
1.83
Aide hours/ resident / day
3.07
Total nurse hours/ resident / day
0.39
RN hoursweekends
50.0%
Total nursing turnover
43.8%
RN turnover

How full it usually is: this home is certified for 74 beds and averages 69.5 residents a day — about 94% occupied, or roughly 4 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 3.07 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.87 hrs/resident/day on weekends vs 3.15 on weekdays — 9% thinner on weekends. RN hours go from 0.68 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

4
deficiencies at the latest standard inspection (2023-08-17)
8
at the previous standard inspection (2020-02-20)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 3 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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · G2025-11-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRCTED PRIOR TO THIS SURVEY Based on record review, staff interview, resident interview, review of the Emergency Medical Services (EMS) run report, review of the hospital documentation, and facility policy review, the facility failed to timely report a fall, failed to complete a timely and thorough resident assessment, and failed to ensure timely care and treatment after a fall. This resulted in Actual harm on 10/12/25 at 12:00 A.M. when Resident #52 fell out of bed and was assisted back into bed by staff without a thorough assessment. On 10/13/25 at 9:15 A.M., Resident #52 screamed out in pain with care, was thoroughly assessed, complained of bilateral leg pain, had x-rays completed, required EMS transportation to the hospital, and was diagnosed with bilateral femur fractures requiring surgical intervention on 10/14/25. The facility census was 68. Review of Resident #52's medical record revealed an admission date of…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · G2025-03-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, resident and staff interview, review of x-ray images, review of orthopedic records, review of therapy notes, review of physician notes, and review of facility corrective action, the facility failed to ensure residents who required assistance with transfers were safely transported in their wheelchair to prevent injury. Actual harm occurred to Resident #10 when a dental provider staff member was transporting the resident in his wheelchair and pushed the resident's right foot into a door frame which resulted in excruciating pain and a subsequent distal posterior tibial fracture to the right foot. Resident #10 required orthopedic follow-up appointments, was required to wear a protective boot, and was non-weight bearing to the right foot until the fracture healed. This deficient practice affected one (#10) of three residents reviewed for accidents. The facility…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · D2026-06-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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, interviews and facility policy review, the facility failed to ensure care plans were developed and updated specifically to the individualized needs of the resident. This affected two residents (Resident #9 and #79) out of 18 residents reviewed for care plans. The facility census was 67.Findings include: 1. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] and discharged on 01/27/26. Review of the admission pressure injury condition report dated 12/16/25 revealed an unstageable dark purple/red area on Resident #79's sacrum. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was admitted with an unstageable pressure ulcer. Review of the non-pressure wound condition report dated 01/26/26 identified Resident #79 had two open wounds to the right mid-thigh, one measuring 1.2 centimeters (cm) length, 0.5 cm width and 0.5 cm depth, and the other measured 0.7 cm length, 0.5 cm width and 0.5 cm length. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, resident representative interview, staff interview, and medical record review, the facility failed to implement and assess for appropriate interventions for a resident at risk for weight loss. This affected one (#2) of two residents reviewed for nutrition. The facility census was 69. Findings include: Review of the medical record for Resident #2 revealed an admission date of 11/15/19. Diagnoses included dementia, rheumatoid arthritis, hypertensive heart disease, chronic pain syndrome, and anemia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was independent with set up for eating and had no significant weight changes. Review of a plan of care dated 10/06/22 revealed Resident #2 was at risk for alteration in nutrition status related to dementia, use of diuretics, decreased mobility, advanced age, and overall decline. Interventions included assistance with meals as needed, two handled cup with lid and straw for drinks, encourage…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-17 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, medical record review, review of a facility policy, the facility failed to administer medications as ordered. There were three medication errors observed out of 27 opportunities for a medication error rate of 11.1 percent (%). This affected two (#46 and #14) of four residents observed for medication administration. The census was 69. Findings include: 1. Observation of medication administration by Registered Nurse (RN) #878 for Resident #46 on 08/16/23 at 8:21 A.M. revealed one of the medications administered was a stool softener Senna 8.6 milligrams (mg) by mouth. RN #878 did not administer Resident #46 a Senna-docusate sodium combination pill during the procedure. Review of Resident #46's medical record, following administration of medication on 08/16/23, revealed there was no active order for Senna 8.6 mg. There was an active order dated 03/10/23 for a Senna-docusate sodium combination pill with a dosage of 8.6-50 mg to be given twice daily for constipation at 9:00 A.M. and 9:00 P.M. Interview with RN #878 on 08/16/23 at 9:44 A.M. verified…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-17 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, medical record review, and review of a facility policy, the facility failed to ensure resident medications were maintained in a safe and secure manner. This affected one (#39) of one residents reviewed for medication storage. The facility census was 69. Findings include: Review of the medical record for Resident #39 revealed an admission date of 02/28/23. Diagnoses included unilateral primary osteoarthritis of the right hip, unspecified pulmonary hypertension, and primary generalized arthritis. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was alert and oriented to person, place, and time and was extensive assist for activities of daily living (ADLs). Review of Resident #23's August 2023 monthly physician orders revealed orders for the diuretic torsemide oral tablet 20 milligrams (mg), the blood pressure medication hydralazine oral tablet 50 mg, the antiemetic medication ondansetron oral tablet four (4) mg, the supplement…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-17 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, medical record review, and review of a meal ticket, the facility failed to provide adaptive eating utensils as ordered and care planned. This affected one (#2) of two residents reviewed for nutrition. The facility census was 69. Findings include: Review of the medical record for Resident #2 revealed an admission date of 11/15/19. Diagnoses included dementia, rheumatoid arthritis, hypertensive heart disease, chronic pain syndrome, and anemia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was independent with set up for eating. Review of a plan of care dated 10/06/22 revealed Resident #2 was at risk for alteration in nutrition status related to dementia, use of diuretics, decreased mobility, advanced age, and overall decline. Interventions included assistance with meals as needed, two handled cup with lid and straw for drinks, encourage the resident to dine in the dining room, offer meal substitutes when foods…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-02-20 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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 observation, medical record review and staff and resident interview, the facility failed to accommodate residents needs by ensuring call lights were within reach and accessible for Resident #25, #58 and #273. This affected three (#25, #58 and #273) of 48 residents reviewed for call light placement. Facility census was 68. Findings include: 1. Record review revealed Resident #273 was admitted to the facility on [DATE] with diagnoses that included but not limited to fracture of lower end of left radius, unsteadiness on feet, and atrial fibrillation. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #273 was moderately cognitively impaired and required extensive assistance of activities of daily living. Review of the care plan falls dated 02/12/20 revealed that call light should be within reach. Observation of Resident #273 on 02/18/20 at 9:36 A.M. revealed Resident #273 was sitting in a recliner with her legs elevated. When this surveyor asked Resident #273 if…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-02-20 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview and policy review, the facility failed to ensure resident nail care was provided. This affected one (#25) of three residents reviewed for activities of daily living. The facility census was 68. Findings include: Medical record review revealed Resident #25 had an admission date of 06/19/19. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus type two, dementia and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had intact cognition. Further review of the MDS assessment revealed the resident required limited assistance from one staff member for personal hygiene. Review of the nurses progress notes dated 01/01/20 through 02/19/20 revealed no documentation the resident had refused nail care. Observation on 02/18/20 at 9:56 A.M. revealed Resident #25's fingernails were long with dark debris underneath the nails. Interview on 02/18/20 at 9:56 A.M. with Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-02-20 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing 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 and resident and staff interviews, the facility failed to provide services to maintain a resident's hearing. This affected one (#37 out of 19 residents sampled for hearing. The facility census was 68. Findings include: Review of Resident #37's medical record identified admission to the facility occurred on 12/26/17. Resident #37 had a medical diagnosis including: Lumbago with sciatica, scoliosis and major depression. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was completely cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of an Audiology visit 09/05/19 identified Resident #37 was alert and oriented time three (person, place and time) was evaluated with an otoscope (device to view ear canal) which identified impacted cerumen (wax) in both ears. The visit report identified hearing tests were not preformed this visit, due to wax in the left ear. Right ear was identified partially blocked. The notes…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-02-20 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff and resident interview, the facility failed to honor resident food preferences. This affected two (#11 and #60) of 19 sampled residents. The facility census was 68. Finding include 1. Medical record review revealed Resident #11 had an admission dated of 11/09/18. Diagnoses included chronic kidney disease, diabetes mellitus type two, Parkinson's disease, anxiety and depressive disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of an undated diet history and food preference sheet revealed the resident preferred cold cereal, cranberry juice and coffee. Further review revealed the resident disliked chicken breasts, chicken legs, corn, and carrots. Review of the resident's dietary meal ticket dated 02/20/20 revealed all the resident's disliked foods were not included on the dietary meal ticket. The meal ticket indicated the resident disliked bananas, potatoes and orange juice. Observation…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-02-20 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    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 family and staff interviews, the facility failed to ensure a resident was provided with eating equipment to maintain independence with eating. This affected one (#30) out of four residents reviewed for maintaining independence with eating. The facility census was 68. Findings include: Review of Resident #30's medical record identified admission to the facility occurred 09/25/15, following a stroked. Resident #30 had additional medical diagnosis including kidney disease, anxiety, dementia and high blood pressure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #30 was not interviewable. Review of Resident #30's nutritional assessment dated [DATE] identified he utilizes a sip cup, but there was no documentation regarding any need for bowls to maintain independence. Resident #30 requires a pureed diet with honey thick liquids. The assessment also identified Resident #30 required being fed by staff and there was no evidence…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2020-02-20 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and policy review, the facility failed to ensure staff wore proper hair restraints while food was being plated in the servery of dining room [ROOM NUMBER]. This affected one of three serveries observed during a meal service. The facility census was 68. Findings include: Observation on 02/18/20 at 12:20 P.M., of the servery in dining room [ROOM NUMBER] revealed License Practical Nurse (LPN) #49 and State Tested Nursing Assistant (STNA) #16 were in the area of the food being plated for the lunch meal without wearing hair restraints and/or a hair net. This was verified by the Dietary Staff (DS) #31. Interview on 02/18/20 at 12:25 P.M., with the Dietary Staff (DS) #31 revealed staff are to wear hair restraints when food is being plated and states, They are wearing them now. Review of facility policy titled Infection Control-Dietary Food Handling, dated 03/2016, revealed the purpose of this procedure is to provide guidelines for the for the safe preparation, handling and storage…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-02-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interviews and policy review, the facility failed to ensure nursing staff adhered to infection control standards during blood glucose monitoring. This affected one (#30) of eight residents observed during medication administration. The facility census was 68. Findings include: Medical record review revealed Resident #30 had an admission date of 09/25/15. Diagnoses included Parkinson's disease, diabetes mellitus type two, chronic kidney disease, and dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the monthly physician orders revealed the resident was order blood glucose monitoring before meals. Observation on 02/19/20 at 6:37 A.M. revealed Registered Nurse (RN) #94 performed blood glucose testing for Resident #30 without wearing gloves. Interview on 02/19/20 at 6:37 A.M., RN #94 verified she forgot to put on gloves prior to testing 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2018-12-19 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, policy review and staff interview, the facility failed to ensure community outings were scheduled for residents in the facility. This affected five residents (#12, #15, #25, #42, and #50) who attended community outings. The facility census was 67. Findings include: Review of facility's Activities calendars revealed an outing in November was scheduled for 11/13/18. No other outing was listed in that month. Further review of calendars revealed no outings to be scheduled for month of December. Interview with Resident #42 on 12/16/18 at 10:33 A.M. revealed outings to have been canceled by facility for winter months. Resident #42 reported that outing scheduled in November had been canceled due to a bus breaking down and was never re-scheduled. Interviews on 12/17/18 at 10:09 A.M. with residents, including Resident #15, #25, #42 and #59, who attended the Resident Council meeting, revealed concerns with the activities programs and lack of outings. Residents expressed feelings of being 'cooped up' and 'down' in facility during winter months. Interview on 12/17/18 at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-12-19 · tag F0553 — failed to let residents help plan their care — isolated
    Allow 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, resident interview, staff interview, and review of a facility policy, the facility failed to provide residents with care planning meetings on a quarterly basis. This affected two residents (#38 and #51) of three residents reviewed for care planning meetings. The facility census was 67. Findings include: 1. Medical record review for Resident #38 revealed an admission date of 12/15/18. Diagnoses included malignant neoplasm of the breast, spinal stenosis, chronic obstructive pulmonary disease, and unspecified mood disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/26/18, revealed the resident was cognitively intact. Review of Resident #38's most recent plan of care revealed care planning would be reviewed with resident and/or responsible party upon admission, quarterly, and as needed and the resident's care planning wishes would be respected. Review of a progress note, dated 02/14/17, revealed a care planning meeting was held with Resident #38, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-12-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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 record review, observations and staff interviews, the facility failed to ensure resident's call lights were within reach. This affected three (#19, #31 and #45) of 67 residents observed for call light placement. The facility census was 67. Findings include 1. Medical record review revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, dementia with behavioral disturbance, hemiplegia and hemiparesis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had cognitive impairment. Observation on 12/16/18 at 1:21 P.M. revealed Resident #45 was sitting in her wheelchair in her room. Further observation revealed Resident #45's call light was clipped to her bed and not within her reach. Interview on 12/16/18 at 01:23 PM with State Tested Nursing Assistant (STNA) #103 verified Resident #45's call light was not within her reach. 2. Medical record review revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-12-19 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interview, the facility failed to ensure the physician was informed of a resident's continuous refusal of care. This affected one (Resident #69) of three residents reviewed for nutrition. The facility census was 67. Findings include: Record review revealed Resident #69 was re-admitted to the facility on [DATE]. Diagnoses included cerebral infarction, type two diabetes mellitus, malignant neoplasm of larynx, tracheostomy status, muscle weakness and gastrostomy status. Review of the most recent nursing assessment, dated 12/18/18, revealed Resident #69 to have no cognitive impairment, needed staff assist for bed mobility, transfers, tube feeding, toileting, dressing, and ambulation. Review of the most recent physician orders revealed Resident #69 to have a current order for nothing by mouth (NPO) diet with enteral feed order of Diabetisource 250 milliliters (ml.) gravity feedings six times per day. Review of the nutrition assessment, dated 12/07/18 revealed Resident #69…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-12-19 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a self-reported incident (SRI), an employee statement, staff and resident interviews and review of facility policy, the facility failed to follow their abuse policy requirement to immediately report an allegation of misappropriation to the State Agency. This affected one (#60) of one resident reviewed for misappropriation. The facility census was 67. Findings include Medical record review revealed Resident #60 was admitted to the facility on [DATE]. Diagnoses included cellulitis of the right lower limb, chronic kidney disease, type diabetes mellitus, kidney transplant and pancreas transplant. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had impaired cognition. Review of a facility self-reported incident (SRI) dated 12/16/18 revealed on 12/14/18 Resident #60 realized his wallet was not in his duffle bag. Resident #60 reported the missing wallet to a nurse. The nurse reported the missing wallet to the Director of Nursing (DON). Review of an…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-12-19 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a self-reported incident (SRI), an employee statement, staff and resident interviews and review of facility policy, the facility failed to immediately report an allegation of misappropriation to the State Agency. This affected one (#60) of one resident reviewed for misappropriation. The facility census was 67. Findings include Medical record review revealed Resident #60 was admitted to the facility on [DATE]. Diagnoses included cellulitis of the right lower limb, chronic kidney disease, type diabetes mellitus, kidney transplant and pancreas transplant. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had impaired cognition. Review of a facility self-reported incident (SRI) dated 12/16/18 revealed on 12/14/18 Resident #60 realized his wallet was not in his duffle bag. Resident #60 reported the missing wallet to a nurse. The nurse reported the missing wallet to the Director of Nursing (DON). Review of an investigation statement dated 12/14/18 written…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-12-19 · tag F0711 — isolated
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    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 ensure the physicians wrote new orders for residents and progress notes at the time of their visits. This affected one resident (#31) of one resident reviewed for physician visits. The facility census was 67. Findings included: Medical record review revealed Resident #31 admitted to the facility on [DATE]. Diagnoses included muscle weakness, ataxic gait, schizoaffective disorder bipolar type, and depression. Review of Resident #31's nursing progress notes revealed on 12/10/18 at 6:00 P.M., the resident's alarm was sounding and staff found the resident face down on the floor next to her wheelchair. No injury was noted and neurological monitoring was initiated. Review of Resident #31's skin assessments revealed on 12/11/18, the resident had bruising under both eyes and to her forehead. Review of Resident #31's physician visits revealed on 12/12/18, the resident's was seen by the physician and noted to have black eyes after a fall with 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-12-19 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure residents did not receive unnecessary opioid pain medication when they failed to assess and document the location of resident's pain. The facility further failed to attempt non-pharmacological interventions prior to the administration of as needed opioid pain medication. This affected one resident (#15) of five residents reviewed for unnecessary medications. The facility census was 67. Findings include: Medical record review for Resident #15 revealed an admission date of 07/15/18. Diagnoses included chronic respiratory failure, chronic kidney disease, and obstructive sleep apnea. Review of Resident #15's physician orders revealed an order dated 12/01/18 for Norco (Opioid pain medication) 5-325 milligrams (mg.) one tablet every 12 hours as needed for pain. Review of the most recent plan of care revealed Resident #15 was at risk for pain or alteration in comfort related to restless leg syndrome, peripheral vascular disease, mobility impairments, arthropathy, and peptic ulcer…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-12-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to identify target behavior appropriate of psychosis for use of antipsychotic medication. This affected one (Resident #47) of five residents reviewed for unnecessary medication and regimen review. The facility census was 67. Findings include: Record review revealed Resident #47 was admitted to the facility on [DATE]. Diagnoses included unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, unspecified dementia without behavioral disturbance, anxiety disorder, low back pain, difficulty in walking, muscle weakness, and unsteadiness on feet. Review of most recent quarterly psychosocial assessment revealed Resident #47 to have clear speech, adequate hearing, understands others and was understood. Resident noted to be alert and oriented to person, time, and place. No changes recorded in mood and nursing was aware and monitoring due to resident having history of feeling down, tired, having poor appetite…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2020-02-20 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on personnel file review, review of the employee handbook, review of a job description and staff interview, the facility failed to ensure performance evaluations were completed as required for State tested nursing assistants (STNAs). This affected four STNAs (#2, #19, #35, and #88) of eight STNAs whose personnel files were reviewed and had the potential to affect all 68 residents residing in the facility. Facility census was 68. Findings include: On 02/18/20 from 5:48 P.M. through 7:02 P.M. with Human Resources Director #75 revealed the following STNA files did not contain 90-day or annual performance evaluations: Review of the personnel file for STNA #2 revealed a hire date of 10/10/18. Review of the employee's personnel file revealed no annual performance evaluation had been completed for 2019. Review of the personnel file for STNA #19 revealed a hire date of 11/19/18. Review of the employee's personnel file revealed no annual performance evaluation had been completed for 2019. Review of the personnel file for STNA #35 revealed a hire date of 02/05/19. 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has plan of correction
  • No harm found · C2018-12-19 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview, the facility failed to ensure the posted daily staffing was updated daily. This had the potential to affect all 67 residents residing in the facility. Findings include: Observation on 12/16/18 at 8:12 A.M., of the facility's posted daily staffing in the front lobby, revealed the posting was dated 12/14/18. No staff posting for 12/16/18 was observed. Interview on 12/16/18 at 8:24 A.M., Dietary Manager (DM) #304 verified the posted daily staffing was dated 12/14/18. DM #304 further verified there was not any staff posting for 12/16/18. Interview on 12/17/18 at 3:55 P.M., the Director of Nursing revealed nursing staff was responsible for making sure the posted daily staffing was changed daily.

    Nursing and Physician Services Deficiencies · Deficient, Provider has plan of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$26,685 in federal fines across 1 penalty.

  • $26,685 — penalty dated 2025-11-06

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 FOUNDATIONS HEALTH SOLUTIONS — 64 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 54.1≈ chain avg
Health inspection 3 of 53.9-0.9 vs chain
Staffing 2 of 52.3-0.3 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 63 homes this chain runs (chain average 4.1★, per CMS)
1 of 5Inniswood Health and RehabilitationWesterville, OH 2 of 5Canterbury Villa Of AllianceAlliance, OH 2 of 5Park Health CenterSt Clairsville, OH 2 of 5Tuscany GardensPataskala, OH 2 of 5Veranda Gardens Nursing & Rehabilitation CenterCincinnati, OH 3 of 5Arlington Care CenterNewark, OH 3 of 5Bennington Glen Nursing & Rehabilitation CenterMarengo, OH 3 of 5Cumberland Pointe Care CenterSt Clairsville, OH 3 of 5Emerald Pointe Health And Rehab CtrBarnesville, OH 3 of 5Hickory Ridge Nursing & Rehabilitation CenterAkron, OH 3 of 5Home At Taylor's PointeCincinnati, OH 3 of 5McNaughten Pointe Nursing And RehabColumbus, OH 3 of 5Meadow Grove Transitional CareGrove City, OH 3 of 5The Gables Of Marysville Health And RehabilitationMarysville, OH 3 of 5The Gardens Of Fairfax Health Care CenterCleveland, OH 3 of 5Timberland Ridge Nursing & RehabilitationFairlawn, OH 4 of 5Austin Trace Health And RehabilitationCenterville, OH 4 of 5Batavia Nursing Care CenterBatavia, OH 4 of 5Claymont Health And RehabilitationUhrichsville, OH 4 of 5Crown Pointe Care CenterColumbus, OH 4 of 5Florentine GardensLoveland, OH 4 of 5Hickory Creek Of AthensThe Plains, OH 4 of 5Jefferson Healthcare CenterJefferson, OH 4 of 5Lafayette Pointe Nursing & Rehab CtrWest Lafayette, OH 4 of 5Maria Joseph Living Care CenterDayton, OH 4 of 5Mill Creek Nursing & RehabilitationGalion, OH 4 of 5Respiratory And Nursing Center Of DaytonMoraine, OH 4 of 5Sycamore Run Nursing And Rehab CtrMillersburg, OH 4 of 5Waterview Pointe Nursing & RehabilitationMarietta, OH 5 of 5Admirals Pointe Nursing & RehabilitationHuron, OH 5 of 5Brunswick Pointe Transitional CareBrunswick, OH 5 of 5Capri GardensLewis Center, OH 5 of 5Carington ParkAshtabula, OH 5 of 5Concord Health & Rehab CtrWheelersburg, OH 5 of 5Concord Ridge Health And RehabilitationMentor, OH 5 of 5Country View Of SunburySunbury, OH 5 of 5Darby Glenn Nursing And Rehabilitation CenterHilliard, OH 5 of 5Glen MeadowsHamilton, OH 5 of 5Golden Years Nursing CenterHamilton, OH 5 of 5Highbanks Care CenterColumbus, OH

Showing 40 of 63; lowest-rated first.

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 / managerTypeRoleSince
COLLERAN, BRIANIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
KRYSTOWSKI, JOHNIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2018
FOUNDATIONS HEALTH SOLUTIONS, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
WAKELING, ALEXISIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/10/2023
ELBADAWY, EMADIndividualADP OF THE SNFsince 06/01/2018

CMS files one row per role, so the 12 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.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$8.6M
Net patient revenuemost recent cost report
+7.6%
Operating marginrevenue minus expenses
$598K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 20%Medicare 8%Other / private 72%

This home reported $598K 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

$311per resident / day
operating cost
$9,454per month
≈ monthly operating cost
$337per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.

Typical monthly cost in Ohio
$9,186/mo
Nursing home (semi-private)
$10,389/mo
Nursing home (private)
$6,103/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366426. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-08-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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