Otterbein Union Township
1114 Neighborhood Drive, Batavia, OH 45103 · Non profit - Corporation · 60 certified beds · (513) 933-5409 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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
- it has 1 actual-harm citation
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $7,008 in federal fines (most recent 2025-08-15)
- nursing-staff turnover (62%) runs well above the national median (45%)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 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 | 6.1% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 4.7% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.8% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.6% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.7% | 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 | 5.8% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.0% | 6.1% | 16.1% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 30.9% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.2% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.9% | 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 | 98.7% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.8% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 16.1% | 12.9% | 12.0% | worse |
‡ 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.
58.1% 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 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 37.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 24 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 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% 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 | 58.1%CMS range 45.5–68.1 | 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 | 12.3%CMS range 8.8–16.6 | 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 | 37.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 37.5% | 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 | 8.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.7%CMS range 3.9–13.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.07 | 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 60 beds and averages 54.4 residents a day — about 91% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.27 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.96 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 4.07 hrs/resident/day on weekends vs 4.35 on weekdays — 6% thinner on weekends. RN hours go from 0.75 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 62% is well above 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · Gcited before2025-08-15 · 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 record review, staff interview, review of self-reported incidents (SRI), review of witness statements, review of personnel files, review of X-ray results, and review of facility policy, the facility failed to ensure Resident #32 was transferred per physician orders and in a manner consistent with her plan of care. This resulted in Actual Harm on 06/22/25 at 4:01 P.M. when Certified Nursing Assistant (CNA) #168 attempted to transfer Resident #32 from the bed to a wheelchair by carrying her without additional staff and without the use of a mechanical Hoyer lift. CNA #168 tripped and fell with Resident #32 and the resident sustained an acute fracture of the right humerus, with mild displacement, and soft tissue swelling. This affected one (Resident #32) of the three residents reviewed for falls. The facility identified 11 additional residents who were dependent on a mechanical lift…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2022-08-12 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to verify a resident's (Resident #55) identity prior to medication administration, resulting in Resident #55 being given another resident's medication. This resulted in actual harm when Resident #55 had a subsequent episode of vomiting and lethargy, leading to the resident being transferred to the emergency room. Additionally, the facility failed to administer pain medication in a timely manner and as ordered by the physician for Resident #107. This affected two (Residents #55 and #107) of six residents reviewed for medication administration. The facility census was 58. Findings included: Medical record review for Resident #55 revealed the resident admitted to the facility on [DATE] with diagnoses including vascular disorder of intestine, chronic kidney disease, essential hypertension, other iron deficiency anemias, unspecified asthma, dyspnea, nonrheumatic mitral valve stenosis, aphasia, asthma, and arthropathy.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-15 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and Record Review, the facility failed to ensure resident care conferences were held quarterly for all residents. This affected Residents #1, #4, #5, #7, #9, #10, #36, and #51. The facility census was 51 at the time of survey. Findings include: 1.Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, type II diabetes mellitus, essential hypertension, and acute kidney failure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of Resident #4's medical records revealed that one care conference was documented on 08/29/25 with no further care documentation of care conferences. Interview on 01/14/26 at 1:50 P.M. with Social Service Director (SSD) #125 verified Resident #4 had no further care conferences for 2025. 2.Review of the medical record revealed Resident #9 was admitted to 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 · Ecited before2026-01-15 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide an ongoing activities program. This affected four residents,(Residents #42, #15, #39 and #16) of four residents reviewed for activities. The facility census was 51.Findings Include: 1.Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses of myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure, hypertension and diabetes mellitus type II, Resident #16 currently serves as the House Council President. Review of the Minimum Data Set (MDS) Medicare Five-Day assessment dated [DATE] revealed Resident #16 had intact cognition and was occasionally incontinent of bowel and always incontinent of bladder. The resident required set up assistance for eating, moderate assistance for oral hygiene, bed mobility and transfers, and maximal assistance for personal hygiene, toileting, bathing and dressing. The resident 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 · E2026-01-15 · tag F0680 — patternEnsure the activities program is directed by a qualified professional.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to provide an activity program directed by a qualified professional. This had the potential to affect 50 residents of the 51 residents receiving the activity program. This did not affect Resident #22. The facility census total was 51. Findings Include: Findings include: Review of personnel file of hired Activity Director, (AD) #90 revealed the AD #90 was hired on 10/21/25. The AD #90 was not licensed or registered by the state. The was no evidence the AD #90 had met the qualifications to be the Activities Director. There was a payment invoice dated on 01/14/26 the AD #90 had been paid to be enrolled in the certification for activity professional.Interviewed with Resident #22 on 01/12/26 at 8:30 A.M. revealed she did not want to attend any activities and did not want any activities provided to her. She wanted left alone in her room and was satisfied with visits from her family.Interview on 01/13/26 at 4:00 P.M. , AD #90 verified she had not met the qualifications to be the Activity Director when she was hired and has 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 · D2026-01-15 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — the official record, unedited, may be distressing
Based on medical record review and staff interview, the facility failed to provide an Advanced Beneficiary Notice of Non-Coverage (ABN) prior to discharge from Medicare Part A services as required. This affected one (Resident #39) of two residents reviewed for ABNs. The facility census was 51.Findings include: Review of SNF Beneficiary Protection Notification Review document for Resident #39 revealed Resident #39 was not issued a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (ABN) Form prior to discharge from Medicare Part A services on 09/29/25. Interview on 01/14/25 at 12:58 PM with the Administrator verified Resident #39, who remained in the facility after the discontinuation of Medicare Part A services on 09/29/25, was not issued the Facility Advanced Beneficiary Notice of Non-Coverage (ABN) Form.
- Potential for harm · D2026-01-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide equipment to prevent physical decline . This affected two residents,(Residents #24 and #42) of two residents reviewed for equipment to prevent physical decline. The facility census was 51. Findings Include: Record review of Resident #24 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #24 include Alzheimer's disease, malnutrition, osteoporosis, adult failure to thrive, and congested heart failure. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and required extensive staff assistance for Activities of Daily Living skills. The resident received hospice care. The resident had physician orders for positioning device to left hand as tolerated and pressure relieving boots at all times as tolerated. Observation on 01/12/26 and 01/13/26 from approximately 9:00 A.M. to 3:30 P.M.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-15 · tag F0810 — isolatedProvide 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 medical record review, observation, staff interview, and review of facility policy, the facility failed to provide adaptive feeding devices as ordered by the physician. This affected two residents (Residents #22 and #42) of two residents for adaptive feeding utensils. The facility census was 51.Findings Include:1.Record review of Resident #42 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #42 include heart failure, malnutrition, myocardial infarction, quadriplegia, and stenosis of carotid artery and left leg amputation. Review of the Minimum Data Set, (MDS) comprehensive assessment dated 12/20 25 revealed the resident had intact cognition and required assistance for feeding. The resident received a regular diet with a order for a built up plate and spoons only. Review of admission notes of 01/05/24 revealed the Resident #42 was admitted with right and left had contractures.Review of plan of care revealed the resident was to receive a plate with sides and spoons 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 · Dcited before2026-01-15 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and review of facility policy, the facility failed to store foods in a safe and sanitary manner. This had the potential to affect all 51 residents who received food from the kitchen. The facility census was 51. Findings include:Observation on 01/12/22 at 8:55 A.M. with Diet Technician #50 revealed the following concerns in House #16's kitchen. 1. An unopened container of cottage cheese with expiration date 01/10/26. 2. Opened cottage cheese opened date of 12/01/26 and expiration date of 02/27/26. Two containers of opened yogurt, one opened 01/08/26 with expiration date of 02/21/26 and the other container labeled opened on 01/01/26 and expiration date of 02/06/26. No containers had a use by or discard date labeled on the containers.3. Review of the food temperature monitor logs revealed on 01/09/26, all three meals had no food temperatures recorded, 01/07/26 had no breakfast temperatures recorded, and 01/10/26 had no breakfast and lunch meal temperatures recorded.4. Review of the dishwasher log of 01/01/26 through 01/11/26 revealed there were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-29 · 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 NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, incident investigation review, and staff interview, the facility failed to provide the appropriate level of assistance during resident transfers. This affected one (Resident #34) of the four residents reviewed for falls. The facility census was 58 residents. Findings include: Review of the medical record for Resident #34 revealed an admission date of 11/07/2023 with diagnoses including heart failure and morbid obesity. Review of the plan of care for Resident #34 dated 11/07/23 revealed the resident was at risk for falls related to impaired mobility, history of falls, history of a fractured femur, and obesity. Interventions included to ensure two staff members provided all check and change care. Review of the Minimum Data Set (MDS) assessment for Resident #34 dated 06/19/24 revealed the resident had moderately impaired cognition and required complete staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-08-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, review of manufacture directions, and review of facility policy, the facility failed to store foods in a safe and sanitary manner. This had the potential to affect all 58 residents who received food from the kitchen. The facility census was 58. Findings include: Observation on 08/01/22 at 8:30 A.M. with Diet Technician #31 revealed the following concerns in House #16's kitchen. 1. Two containers of unidentifiable food, unlabeled and undated. 2. Three quarters of a chocolate pie in a pie pan uncovered and undated. 3. Opened potato salad, undated. 4. Container of opened applesauce, undated. 5. Open container of pineapple undated. 6. Container of opened chicken broth, undated. 7. No thermometer in reach of the refrigerator. 8. An undated pan of partially served brownies. Observation on 08/01/22 at 8:45 A.M. with Diet Technician #31 revealed the following concerns in House #17's kitchen: 1. Container of opened applesauce, undated. 2. Container of opened beef broth with expiration date of 07/27/22. 3. Undated open container of cranberry juice. 4.…
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 · E2022-08-12 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interviews, resident interviews, and review of facility policy, the facility failed to provide sufficient staffing to meet the needs of the residents. This affected one (Resident #107) and had the potential to affect twelve residents (#207, #47, #46, #156, #206, #111, #106, #107, #45, #108, #40 and #31) who resided in House #15. The facility census was 58. Findings included: During initial tour of the facility on 08/01/22 from 8:15 A.M. through 9:20 A.M. revealed the facility had five separate homes. Each home was licensed for twelve residents. There were two nurses, Licensed Practical Nurse (LPN) #92 and Registered Agency Nurse (RN) #120 and eight State Tested Nurse Aides (STNA) (#8, #9, #35, #38, #46, #52, #76, and #82) present in the facility to care for 58 residents residing in the five houses. Review of Resident #107's medical record revealed an admission date of 07/17/22. Diagnoses included pneumonia, hypertension, osteoarthritis, cardiomegaly, gout, presence 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.
Show the remaining 14 citations
- Potential for harm · E2022-08-12 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to provide food portions and menus as approved by a Registered Dietitian. This had the potential to affect all 58 residents who received food from the kitchen. The facility census was 58. Findings Include: Review of the facility's approved menu dated 08/01/22 for House #15's lunch meal revealed the following was to be served: Six ounces (oz) of spaghetti with meatballs, four oz of broccoli, four oz of cottage cheese with peaches, one slice of garlic bread and a beverage. Observation on 08/01/22 at 12:40 P.M. revealed Resident #207 was served five slices of peaches, less than one cup of chicken noddle soup, and one slice of bread with butter. Interview on 08/01/22 at 12:41 P.M. Resident #207 reported the lunch portion was, not much food for anyone. Resident #207 stated the portion sizes were dependent upon which State Tested Nurse Aide (STNA) or how many STNAs were working. Resident #207 also verified menus were not followed. Observation and interview on 8/01/22 at 1:15 P.M. revealed Resident #206 was serviced…
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 · D2022-08-12 · 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 observation, record review, and staff interview, the facility failed to timely notify a physician of a resident's significant weight loss. This affected one resident (#55) out of five residents reviewed for nutrition. The facility census was 58. Findings include: Medical record review revealed Resident #55 admitted to the facility on [DATE] with diagnoses including vascular disorder of intestine, chronic kidney disease, unsteadiness, essential hypertension, other iron deficiency anemias, and morbid obesity due to excess calories. Review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #55 required supervision with eating. Resident #55 was reported to have a five percent or more weight loss in the last month or ten percent or more in the last six months and was not on a prescribed weight loss regimen. 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 · Dcited before2022-08-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide an ongoing activities program. This affected three (Residents #29, #30, and #50) of four residents reviewed for activities. The facility census was 58. Findings include: 1. Medical record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including heart failure, diabetes, and dementia with behavioral disturbance. Review of Resident #29's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The resident activity preferences included group activities, and pet visits. Further review of the medical record and review of the Activity Leisure Logs revealed no documentation showing Resident #29 participated in daily activities. 2. Medical record review revealed Resident #30 admitted to the facility on [DATE] with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff inteview, and resident interview, the facility failed to provide timely incontinence care. This affected one (Resident #107) of three residents reviewed for incontinence care. The facility census was 58. Findings included: Review of Resident #107's medical record revealed an admission date of 07/17/22. Diagnoses included pneumonia, hypertension, osteoarthritis, cardiomegaly, gout, presence of unspecified artificial knee, chronic pain, atrial fibrillation, and diabetes. Review of Resident #107's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS revealed the resident required extensive two-person assistance for bed mobility, transfers, and dressing. The resident was totally dependent with two-person assist for toileting and personal hygiene. The resident required supervision with set-up for eating. Review of Resident #107's plan of care dated 07/17/22 revealed the resident had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 medical record review, observation, staff interview, and review of facility policy, the facility failed to timely monitor and address Resident #55's weight loss and failed to ensure weekly weights were completed as ordered by the physician. This affected one (Resident #55) of five residents reviewed for nutrition. The facility census was 58. Findings include: Medical record review revealed Resident #55 admitted to the facility on [DATE] with diagnoses including vascular disorder of intestine, chronic kidney disease, unsteadiness, essential hypertension, other iron deficiency anemias, and morbid obesity due to excess calories. Review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #55 required supervision with eating. Resident #55 was reported to have a five percent or more weight loss in the last month or…
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 · D2022-08-12 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview and review of personnel files, the facility failed to ensure an annual performance review was completed for State Tested Nursing Assistant (SNTA) #2. This affected one (STNA #2) of two STNAs reviewed for annual performance reviews. This had the potential to affect all residents at the facility. The facility census was 58. Findings include: Review of State Tested Nursing Assistant (STNA) #2's personnel file revealed a date of hire on 02/10/20. Review of the STNA's file revealed no annual performance review was contained in the file. Interview on 08/04/22 at 8:02 A.M. with Business Office Manager #84 confirmed the facility was not able to provide evidence an annual performance review was completed for STNA #2.
- Potential for harm · D2022-08-12 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to identify the reason for the use of as needed (PRN) narcotic pain medications and provide other interventions prior to the administration of pain medications for one (#22) of six residents reviewed for unnecessary medications. The facility census was 58. Findings include: Review of Resident #22's medical record revealed an admission date of 01/06/18. Diagnoses included fracture of unspecified pubis, chronic obstructive pulmonary disease, neuropathy, anxiety disorder, urinary incontinence, chronic pain, and hyponatremia. Review of Resident #22's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of Resident #22's plan of care dated 05/11/22 revealed the resident was at risk for pain related to poly-osteoarthritis, neuropathy, and decreased mobility. Interventions included topical pain medications, range of motion, and administer pain medications as ordered. Review of Resident #22's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, the facility failed to properly label insulin medication. This affected two (Residents #13 and #21) and had the potential to affect 10 residents (#13, #21, #206, #41, #29, #48, #4, #49, #43, #40) who received insulin at the facility. The facility census was 58. Findings include: Observation and interview on 08/03/22 at 11:23 A.M. revealed the medication cart located in House #17 contained two opened, unnamed, multi-use vials of insulin. Neither vial was labeled with a resident's name or the date it was opened. Agency Registered Nurse (RN) #101 confirmed the Lantus 100 units per milliliter (ml) belonged to Resident #13 and the Humalog 100 units per ml belonged to Resident #21. Further observation revealed both bottles were open and approximately half empty. RN #101 confirmed neither insulin vial was labeled with an open-dat and neither insulin vial was in a pharmacy bag or box with the name, order or open date. RN #101 verified all insulin was required to have the opened date written on the vial or container. Review of Resident #13's medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2019-07-31 · 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 observation, record review, policy review and staff interview, the facility failed to discard expired medications, failed to date medications when open to ensure efficacy, and failed to secure controlled medications. This had the potential to affect all residents of the facility. The facility census was 44. Findings include: 1. Review of Resident #43's medication administration record (MAR) revealed Latanoprost eye drops (treats glaucoma) to be administered one drop in each eye twice daily. During a medication storage tour on 07/31/19 at 12:42 P.M. with Registered Nurse (RN) #150 revealed Latanoprost eye drop container in Resident #43's bin. The container was in a clear plastic bag displaying a handwritten date of 06/01/19 that indicated - dispose of after 42 days. RN #150 confirmed the expired date and was unable to locate any other Latanoprost supply for Resident #43. Interview with the Director of Nursing (DON) on 07/31/19 at 11:30 A.M. stated the expired Latanoprost was the only supply available for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-07-31 · 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 record review, staff interview, and review of facility policy, the facility failed to ensure a written notice including reasons for transfer/discharge was provided to the resident, resident's representative, and ombudsman prior to transfer/discharge. This affected one (#35) of three residents reviewed for hospitalization. The facility census was 46. Findings include: Review of Resident #35's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included pneumonitis due to inhalation of food and vomit, chronic obstructive pulmonary disease, major depressive disorder, chronic kidney disease stage four, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/02/19, revealed the resident had severe cognitive impairment. Review of Resident #35's nursing progress notes revealed on 06/14/19, Resident #138 noted the resident appeared to be in respiratory distress and the resident was to sent the emergency department for evaluation and…
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 · D2019-07-31 · tag F0641 — isolatedEnsure 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 record review, observation, resident and staff interview, and review of facility policy, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two (#8 and #32) of 13 residents reviewed for MDS accuracy. The facility census was 46. Findings include: 1. Review of the record for Resident #8 revealed an admission date of 11/08/17 with diagnoses which included chronic obstructive pulmonary disease and asthma. Review of hearing progress notes signed by a nurse practitioner dated 05/07/18, 10/26/18, and 04/11/19 revealed Resident #8 was evaluated and failed a whisper test (a preliminary test for assessing for hearing impairment) and would benefit from an audiology referral. Review of the MDS assessment, dated 04/19/19, revealed the resident was cognitively intact and had adequate hearing. Review of physician orders revealed an order, dated 05/21/19, that resident may be seen and treated by an audiologist. Interview with Resident #8 on 07/29/19 at 10:03 AM confirmed the 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 · Dcited before2019-07-31 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, review of facility policy and staff interviews, the facility failed to revise care plans with fall interventions and specific medical devices in use. This affected two (#21 and #33) of thirteen residents reviewed for care planning. The facility census was 46. Findings include: 1. Review of Resident #21's medical record revealed an admit date of 10/08/18 with diagnosis including dementia, osteoarthritis, neuropathy, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 04/19/19, indicated the resident had moderate cognitive impairment, no behaviors or rejections of care, and extensive assist of two for all activities of daily living. Review of the fall care plan, dated 10/18/18, included to utilize a stand pivot disc with two staff for transfers. The care plan was silent for a revision to the use of foot pedals on the wheelchair. Review of a progress note, dated 06/20/19 at 8:42 P.M.,. revealed a nurse responded to a 9-1-1 page and found Resident #21 lying on her back and state tested nurse assistant (STNA)…
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 · D2019-07-31 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, resident and staff interview, and review of the facility policy, the facility failed to ensure that residents received treatment for hearing loss. This affected one (Resident #8) of two residents reviewed for communication and sensory concerns. The facility census was 46. Findings include: Review of the record for Resident #8 revealed an admission date of 11/08/17 with diagnoses which included chronic obstructive pulmonary disease and asthma. Review of the Minimum Data Set (MDS) assessment, dated 04/19/19, revealed the resident was cognitively intact, had adequate hearing and did not wear hearing aids. Review of hearing progress notes signed by a nurse practitioner dated 05/07/18, 10/26/18, and 04/11/19 revealed Resident #8 was evaluated and failed a whisper test (a preliminary test for assessing for hearing impairment) and would benefit from an audiology referral. Review of physician orders for Resident #8 revealed an order, dated 05/21/19, that resident may be seen and treated by an audiologist. Interview with Resident #8 on 07/29/19 at 10:03 AM confirmed…
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 · D2019-07-31 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to administer a resident's medication as ordered by the physician. This affected one (#5) of thirteen residents reviewed in the final sample. The facility identified all 46 residents receive medications administered by the facility nurses. Findings include: Review of Resident #5's medical record revealed an admit date of 11/09/17 with diagnoses included dementia, hypertension and heart disease. Review of the Minimum Data Set (MDS) assessment, dated 07/05/19, indicated the resident had impaired cognition with behaviors. Review of the physician orders for July 2019 revealed an order, dated 07/23/19, for Clonidine (antihypertensive medication) 0.1 milligrams to be administered as needed for a systolic blood pressure greater than 160, not to exceed twice per day. Review of the Medication Administration Record (MAR) for July 2019 revealed results of blood pressure measurements five times per day. The MAR revealed from 06/23/19 to 06/29/19 sixteen blood pressures exceeded 160 systolic: on 07/23/19 at 10 A.M. 170/88; at 2 P.M.…
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
$7,008 in federal fines across 1 penalty.
- $7,008 — penalty dated 2025-08-15
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 OTTERBEIN SENIORLIFE — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 3.0 | ≈ chain avg |
| Staffing | 3 of 5 | 3.2 | -0.2 vs chain |
| Quality measures | 4 of 5 | 4.1 | ≈ chain avg |
The other 19 homes this chain runs (chain average 3.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| OTTERBEIN NEIGHBORHOODS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2016 |
| OTTERBEIN HOME | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 12/01/2021 |
| GREEN, JAMES | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 11/21/2005 |
| WILSON, JILL | Individual | CORPORATE OFFICER | — | since 05/01/2009 |
| FUNCTIONAL PATHWAYS OF TENNESSEE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/03/2025 |
| APP, LYNN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| ARNOLD, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/03/2018 |
| BARTLETT, VICTORIA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BAYLIFF, BECKY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BROWNSON, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BURKE, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| CHINTA, VIJAYALAKSHMI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2018 |
| COLEMAN, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| FRALEY, RALPH | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| GLOSSER, HEIDI | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| HAWKINS, RITA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/17/2015 |
| HAZELBAKER, TOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| HILL, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/16/2023 |
| VONDERHAAR, STEVE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| BAKER, STEVE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| GALBUT, ABRAHAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| GALBUT, DANIEL | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/05/2025 |
| GALBUT, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| GALBUT, ERIC | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/05/2025 |
| GALBUT, ROBERT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| PARITZKY, JONATHAN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| ROMBRO, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| ZISEK, TODD | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/04/2025 |
| POLARIS PHARMACY SERVICES OF OHIO LLC | Organization | ADP OF THE SNF | — | since 12/01/2018 |
CMS files one row per role, so the 35 rows in the source record cover these 29 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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 $391K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366439. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, 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.