O'neill Healthcare Bay Village
605 Bradley Rd, Bay Village, OH 44140 · For profit - Limited Liability company · 138 certified beds · (440) 871-3474 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- about 22% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 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 | 2.5% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 4.6% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 50.3% | 30.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.2% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 3.2% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 23.6% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 91.6% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.4% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.7% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.0% | 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 | 81.9% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 30.0% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.7% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.60 | 1.73 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.84 | 1.80 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
36.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 143 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 77.3% 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 66 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 0.35 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 | 36.2%CMS range 28.9–43.5 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 8.1–14.2 | 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 | 77.3% | 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 | 59.1% | 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 | 59.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 76.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 97.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 | 1.1% | 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 | 8.2%CMS range 4.7–13.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.76 | 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 138 beds and averages 112.3 residents a day — about 81% occupied, or roughly 26 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.34 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 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 2.93 hrs/resident/day on weekends vs 3.51 on weekdays — 17% thinner on weekends. RN hours go from 0.71 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · Fcited before2026-01-21 · 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, interview, and facility policy, the facility failed to ensure proper food storage and sanitation of the food preparation and storage area. This had the potential to affect all residents residing in the facility. The facility census was 117.Findings include: Observations during the initial kitchen tour on 01/13/26 at 8:30 A.M. with the Dietary Manager (DM) #586 revealed the following: Observation of the dry storage area, four containers of lemon-flavored thickened water were identified with an expiration date of 10/07/24. Thirteen packages of submarine rolls were observed in storage labeled with a best-by date of 01/10/26. Additionally, three yellow onions were observed with visible root growth, stored in a container in which multiple fruit flies were actively present. The floor of the dry storage area was observed to be visibly soiled, with scattered trash including clear plastic wrap, black dirt, a dark liquid-like substance, and areas of sticky residue. The main cooler revealed one opened to air and undated pack of hot dogs, one undated bowl of unidentified…
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 · F2026-01-21 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, work orders, facility policy review and facility documents review, the facility failed to ensure an effective pest control program in the kitchen area and failed to ensure garbage receptacles had lids. This had the potential to affect all residents receiving food from the kitchen. The facility census was 117.Findings include:Observation of the main kitchen on 01/13/26 at 8:30 A.M. with the Dietary Manager (DM) #586 revealed several fruit flies were near the main freezer and juice dispenser. Three garbage receptacles in the kitchen had visible trash with no lids. Fruit flies were observed in the trash and in the yellow onion storage container. Interview on 01/13/26 with DM #586 at the time of the observation verified the findings.Review of work orders from the facilities contracted pest control company revealed the main kitchen was treated for fruit flies and general pests on 08/14/25, inspected for ants and fruit flies on 09/11/25, spot treated for fruit flies on 10/09/25, inspected for fruit flies on 11/13/25, spot treated for fruit flies on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-21 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, family interview, resident interview, and facility policy review, the facility failed to ensure foods were served at a palatable temperature and were visually pleasing. This affected sixteen (Residents #1, #4, #24, #25, #26, #28, #31, #48, #59, #65, #71, #72, #85, #98, #116, and #137) of 18 residents reviewed for dietary services. The facility census was 117. Findings include: 1. Interview with a family member of Resident #48 on 01/12/26 at 10:30 A.M. revealed multiple concerns related to food quality and temperature.2. Interview with Resident #137 on 01/12/26 at 10:55 A.M. revealed the food at the facility is always cold and Resident #137 has to ask the facility's Certified Nursing Assistants (CNAs) to warm up the food, which they do reluctantly.3. Interview with Resident #116 on 01/12/26 at 11:16 A.M. revealed the food had gone downhill.4. Interview with Resident #1 on 01/12/26 at 12:37 P.M. revealed the food at the facility is gross.5. Observation of the test tray for the breakfast meal on 01/13/26 at 8:00 A.M. with Dietary Manager (DM) #586 revealed 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 · E2026-01-21 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, and staff interview, the facility failed to maintain a clean and sanitary environment. This affected 15 Residents (#4, #5, #10, #21, #26, #28, #32, #33, #40, #48, #50, #71, #78, #91, and #94) of 117 residents observed during the survey and had the potential to affect all residents residing in the facility. The facility census was 117.Findings include:Observation during environmental rounds on 01/15/2026 at 9:42 A.M. with the Director of Ancillary Services (DAS) #645 revealed the following that was verified at the time of discovery:- Resident #4's room had loose flooring under the bottom of the bed legs.- Resident #5's bottom bed sheet had a small hole and two small yellow stains at the end of the bed. There was a strong odor of urine in the room, but there was no visible urine.- Resident #10's room had an air conditioner filter that had visible dirt and debris. There was wall damage behind the bed.- Resident #26's room had loose flooring under three of four bed legs, and a dislodged floor baseboard cover and exposed heating element.-…
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 · D2026-01-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure a safe and homelike environment. This affected two residents (#26 and #81) of 26 sampled residents. The facility census was 117. Findings include: Observation on 01/15/26 at 9:42 A.M. of Resident #26's room revealed a rolled towel which was placed at the base of the room window next to the bed. Cold air was felt from the base of the closed window. Interview on 01/15/26 at 10:05 A.M. with Resident #26 revealed that cold air comes through the window and is uncomfortable, and that is why the rolled towel is placed.Observation on 01/15/26 at 9:45 A.M. of Resident #81's room revealed a gap above the air conditioner unit below the window. Cold air was felt through the gap.Interview on 01/15/26 at 9:42 A.M. with Resident #81 revealed the resident stated he was cold in his room and was uncomfortable.Interview and environmental rounds on 01/15/26 at 2:25 P.M. with the Director of Ancillary Services (DAS) #645 confirmed the above findings.This deficiency represents non-compliance investigated under Complaint Numbers 2642470,…
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 · D2026-01-21 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) accurately captured all of the resident's current mental health and intellectual disability conditions. This affected one resident (#98) of one resident reviewed for PASARR. The facility census was 117.Findings include: Resident #98 was admitted to the facility on [DATE] with diagnoses that included unspecified intellectual disabilities, schizoaffective disorder, major depressive disorder, and Alzheimer's disease.Review of Resident #98's most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #98 was moderately cognitively impaired and required hands-on assistance from one staff person to complete activities of daily living.Review of the Preadmission Screening and Resident Review (PASARR) assessment dated [DATE] revealed the facility failed to accurately identify Resident #98's mental health and intellectual disability diagnoses. Specifically, 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 · D2026-01-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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, interview, and facility policy review, the facility failed to ensure Resident #31 had an activities care plan including the resident's choices and preferences for activities. This finding affected one (Resident #31) of one resident reviewed for activities. The facility census was 117. Findings include:Review of Resident #31's medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinson's Disease without dyskinesia, diabetes and muscle weakness.Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #31's care plans did not reveal evidence of a care plan that was implemented to reflect the resident's choices or preferences for activities.Interview on 01/12/26 at 10:10 A.M. with Resident #31 revealed some activities were cancelled due to lack of resident participation.Interview on 01/20/26 at 10:04 A.M. with Activity Director (AD) #542 confirmed Resident #31'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 · D2026-01-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, and facility policy review, the facility failed to ensure residents were involved in their ongoing plan of care. This affected one resident (#116) of 26 residents reviewed for care planning. The facility census was 117.Findings include: Resident #116 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis (paralysis and weakness), hypertension (high blood pressure), osteoarthritis, major depressive disorder, vertigo, and anxiety disorder. Review of the electronic medical record for Resident #116 revealed the last social service assessment progress note was recorded on 10/31/23, and social service progress note on 05/01/24. There was no documentation in the electronic medical record of a care conference from 10/31/23 to 01/13/26. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #116 was cognitively intact and required set up to partial/moderate assistance for completing his…
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 · D2026-01-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review, the facility failed to comprehensively assess a newly identified skin alteration to Resident #8's sacral/buttock area and ensure the resident's care plan for pressure ulcer prevention and treatment was timely revised. This affected one resident (#8) of two residents reviewed for pressure ulcers. The facility census was 117.Findings include:Resident #8 was admitted on [DATE] which included diagnoses of senile degeneration of brain, emphysema, heart block, emphysema, obstructive and reflux uropathy, hyperlipidemia, heart failure, and atrial fibrillation.Review of the admission Nursing Data Collection Tool dated 11/11/25 at 6:30 P.M. revealed Resident #8 had no pressure areas upon admission. The skin condition on admission revealed scattered bruising to the bilateral upper extremities, a right chest abrasion, a left groin abrasion, bruising and scabs to the right trochanter (hip), scabs to the right forearm, and a surgical incision 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 · D2026-01-21 · 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 medical record review, witness statements, policy review, and interview, the facility failed to ensure Resident #121 was transferred appropriately using a Hoyer mechanical lift. This finding affected one (Resident #121) of two residents reviewed for transfers. The facility census was 117. Findings include:Review of Resident #121's medical record revealed the resident was admitted on [DATE], readmitted on [DATE] and discharged on 09/05/25 with diagnoses including chronic obstructive pulmonary disease, lumbago with sciatica right and left side and chronic atrial fibrillation. Review of Resident #121's Mobility Care Plan revealed an intervention dated 11/30/23 to transfer the resident with the assistance of two staff members using a Hoyer mechanical lift and the medium purple sling. Review of Resident #121's physician orders revealed an order dated 03/01/24 for a Hoyer lift for all…
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 18 citations
- Potential for harm · D2026-01-21 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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, interview, facility policy review, and review of manufacturer's guidelines, the facility failed to ensure medication error rates did not exceed 5%. This affected two residents (#40 and #97) of five residents observed for medication administration. A total of 29 opportunities with two errors were identified which resulted in a medication error rate of 6.9%. The facility census was 117.Findings include:1. Review of Resident #40's medical record revealed the resident was admitted on [DATE] with diagnoses including schizophrenia, type two diabetes mellitus with diabetic neuropathy and generalized anxiety disorder. Review of Resident #40's physician orders revealed an order dated 03/16/25 for Humalog KwikPen (short acting insulin) per sliding scale with meals for diabetes to inject 1 unit for a blood sugar of 151 to 200; 2 units for a blood sugar 201 to 250; 3 units for a blood sugar of 251 to 300; 4 units for 301 to 350; 5 units for 351 to 400; and greater than 400 give six units…
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 · D2026-01-21 · tag F0774 — isolatedHelp the resident with transportation to and from laboratory services outside of the facility.
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, record review, and facility policy review, the facility failed to ensure transportation was adequately setup for Resident #31's outside appointments. This finding affected one (Resident #31) of three residents reviewed for outside appointments. The facility census was 117. Findings include:Review of Resident #31's medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinson's Disease, muscle weakness, and cognitive communication deficit.Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #31's physician orders revealed an order dated 12/02/25 for an appointment to podiatry on 12/04/25 at 11:15 A.M. and an order dated 01/05/26 for an appointment on 01/08/26 at 2:15 P.M. to the foot doctor. Review of Resident #31's medical record revealed the resident was currently insured by an Ohio managed Medicaid.Interview on 01/12/26 at 10:10 A.M. with Resident #31…
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 · D2026-01-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to implement appropriate infection control measures during wound care. This affected one resident (#10) of three residents reviewed for wound management. The facility census was 117. Findings include: Review of the medical record revealed Resident #10 was admitted on [DATE] with diagnosis of hemiplegia, hemiparesis, type II diabetes, dysphagia, cerebral infarction a stoke, depression, anxiety, contracture right knee, hypertension heart, and heart failure.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively impaired and dependent on staff for hygiene and transfers. The resident had a stge II pressure ulcer and moisture associated skin damage (MASD).Review of the Care Plan dated 11/13/25 stated Resident #10 required Enhanced Barrier Precautions (EBP) related to multidrug resistant organism (MDRO) infection in the right foot wound. Review of the physician orders for January…
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 · D2026-01-21 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
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 and staff interview, the facility failed to ensure a functional call light system was in place for Residents #4 and #16. This affected two (Residents #4 and #16) of 26 sampled residents. The facility census was 117.Findings include:1. Resident #16 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, osteoarthritis and major depressive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 was cognitively intact and was dependent on staff for completing his activities of daily living. Interview with Resident #16 on 01/12/26 at 4:45 P.M. revealed concerns related to the functionality of Resident #16's call light. Observation of Resident #16's call light on 01/12/26 at 4:50 P.M. revealed a red cord was looped through a hole in a switch affixed to the wall with a note above the switch plate which read, Pull For Nurse. The red cord lead from the switch down through an eyelet at the bottom of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-11 · 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
Based on observation, record review, and interview, the facility failed to ensure care and treatment to a skin tear was completed per physician order. This affected one resident (Resident #109) of two residents reviewed for wound care. The facility census was 107. Findings include: Review of the medical record for Resident #109 revealed an admission date of 11/08/24 with diagnoses including stroke, diabetes mellitus, kidney disease, anxiety, post-traumatic stress disease, and cognitive impairment. Review of the progress note dated 02/25/25 at 8:26 A.M. revealed Resident #109's wife was notified of Resident #109 being transferred for evaluation after experiencing a fall on 02/24/25 at 7:00 A.M. Review of an active physician order dated 02/25/25 revealed Resident #109 was to have a left-hand skin tear cleansed with normal saline, patted dry, triple antibiotic ointment applied, covered with non-adherent dressing and wrapped with gauze once daily until healed. Observation of the Resident #109 on 02/26/25 at 11:32 A.M. revealed a left-hand laceration with four steri-strips covering 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 · Dcited before2025-03-11 · 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 observations, record reviews, staff interviews, and review of facility policies the facility failed to provide nutritional and hydration care and services to meet the needs of one resident (Resident #108) out of three residents reviewed for nutrition and hydration and of eight facility identified eight residents requiring feeding assistance. The facility census was 107. Findings include: Review of the medical record for Resident #108 revealed an admission date of 01/23/25 and a discharge date of 02/10/25. Diagnoses included encephalopathy (brain function impairment), dysphagia (difficulty swallowing), failure to thrive, chronic respiratory disease, hypertension, muscle weakness, atrophy (muscle wasting), anxiety, Alzheimer's disease, depression, and bipolar disorder. Review of the admission minimum data set (MDS) assessment completed 02/03/25 revealed Resident #108 had severely impaired cognition. The Resident #108 was dependent on staff for all self-care and required assistance for eating. 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 · D2024-12-31 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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, interview, record review, and review of the facility policy, the facility failed to ensure residents had their call lights within reach while unattended in their rooms. This affected three residents (#36, #39, and #43) out of 13 residents reviewed call light placement. The facility census was 108. Findings include: 1. Record review for Resident #39 revealed an admission date of 12/19/24. Diagnoses included displaced fracture of the base of the neck of the left femur, muscle weakness and dementia. Review of the Functional Assessment for Resident #39 dated 12/19/24 at 4:15 P.M. completed by Licensed Practical Nurse (LPN) #241 revealed Resident #39 had no impairment to the upper extremities and impairment to one side of the lower extremities. Resident #39 was dependent on staff for bed mobility. Review of the Interim Care Plan for Resident #39 dated 12/19/24 at 4:12 P.M. revealed Resident #39 was at risk for falls and fall related injuries, interventions included call light/items within reach.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-31 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 record review, interview, review of the facility self-reported incident (SRI) and review of the facility policy, the facility failed to timely report an allegation of abuse for Resident #111. This had the potential to affect one resident (#111) of three residents reviewed for abuse. The facility census was 108. Findings include: Record review for Resident #111 revealed an admission date of 11/16/24 and a discharge date of 11/30/24. Diagnoses included metabolic encephalopathy, cirrhosis of the liver, acute respiratory failure with hypoxia, muscle weakness, atherosclerotic heart disease, history of transient ischemic attack (TIA), acute kidney failure, and atrial fibrillation. Review of the Medicare five-day Minimum Data Set (MDS) assessment for Resident #111 revealed the resident was cognitively intact. Resident #111 used a walker for mobility, had no impairment to upper extremities, impairment on one side of the lower extremities, was independent with eating, dependent on staff for toileting, partial…
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 before2024-06-12 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide 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, interview, record review, and facility policy review the facility failed to provide fortified pudding to residents as an intervention for maintaining weight, wound care and/or preventing weight loss. The affected five residents (#16, #27, #29, #60 and #94) out of 15 residents who were to receive fortified pudding at lunch either by physician order or dietitian recommendation. The facility census was 111. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 09/27/18 and a readmission date of 10/13/20. Diagnoses included but not limited to dementia, personal history of malignant neoplasm of large intestine, and diabetes mellitus. Review of the physician's order for June 2024 revealed that Resident #16 was ordered fortified pudding at lunch daily. Review of Resident #16's care plan dated 04/11/24 revealed that he was at risk for altered nutrition/hydration related to diagnoses. Interventions included but not limited to encouraging intake of high…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-12 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, taste test and recipe review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing for Residents #18, #66, and #110. This affected three residents (18, #66 and #110) out of three residents who were prescribed pureed diets. The facility census was 111. Findings include: Observation of tray line on 06/10/24 from 11:30 A.M. through 1:02 P.M. revealed that the puree peas appeared to be lumpy. A taste test of pureed peas revealed that there were pieces of the pea shells and were not smooth in consistency. A taste test on 06/10/24 at 11:42 A.M. with Speech Therapist (ST) #404 verified that the pureed food was not a smooth consistency. Review of the facility's spreadsheet for the day on 06/10/24 at the bottom revealed pureed foods should hold their shape on a spoon and smooth texture. This deficiency represents non-compliance investigated under Master Complaint Number OH00154405.
- Potential for harm · D2024-06-12 · tag F0806 — failed to honor food preferences — isolatedEnsure 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
Based on observation, interview, and record review, the facility failed to ensure resident food allergies and preferences were honored. This affected two residents (#43 and #111) who had food allergies and one resident (#69) for food preferences. This had the potential to affect 110 residents out of 111 residents who received meals from the facility kitchen. The facility identified one resident (#30) who received nothing by mouth. The facility census was 111. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 11/11/22. Diagnoses included but not limited to hemiplegia affecting the left side, anxiety disorder, and depression. Review of the physician's order for June 2024 revealed that Resident #43 was allergic to chocolate. Review of the lunch diet ticket for Resident #43 revealed that the resident was allergic to chocolate. Observation of tray line on 06/10/24 at 12:24 P.M. revealed Dietary Aide #407 checked Resident #43's tray and put it into the food cart. When asked, Dietary Aide #407 pulled the tray out of the food cart and 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.
- Potential for harm · Fcited before2024-03-13 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview and facility policy review, the facility failed to ensure food was served in a sanitary manner and food was stored and dated properly. This had the potential to affect 114 residents receiving meals from the facility. The facility identified three residents (#14, #113, and #168) who received nothing by mouth. The facility census was 117. Findings include: A tour of the kitchen was conducted on 03/10/24 from 9:05 A.M. to 9:55 A.M. with Dietary Manager #200. The following concerns were observed during the kitchen tour. In the dry storage area, five packages of eight count Italian split sub buns were found with a use by date of 03/05/24, one package of 12 count hamburger buns with a use by date of 03/05/24. In the walk in refrigerator, a Ziploc bag with ham slices was found with a date of 02/28/24, a plastic container of egg salad dated 03/05/24, a plastic container of sliced peaches dated 03/05/24, a plastic container of sliced cucumbers dated 03/05/24 which appeared to be slimy, an unlabeled, undated Ziploc bag of cooked bacon slices, a Ziploc bag…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-13 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure the appropriate state agency (The Ohio Department of Mental Health and Addiction Services) was notified of a significant change in a resident's Pre-admission Screen and Resident Review (PASRR). This affected one (Resident #88) of one resident reviewed for PASRR status. The facility census was 117. Findings include: Clinical record review revealed Resident #88 was admitted to the facility on [DATE] with diagnoses that included but were not limited to metabolic encephalopathy, unspecified dementia, type II diabetes mellitus, schizoid personality disorder and major depressive disorder. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #88 had severe cognitive impairment and required extensive assistance for completion of activities of daily living. Review of the PASRR form dated 08/01/23 for Resident #88 revealed no indications of serious mental illness and/or developmental disability.…
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 before2024-02-15 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, food committee review, and review of the policy, the facility failed to ensure food was served at the preferred temperature. This had the potential to affect all residents residing at the facility, with the exception of two residents (#33 and #34) who received nothing by mouth. The facility census was 114. Findings include: Review of food committee minutes dated 01/09/24 at 1:30 P.M., revealed residents expressed concerns with hot food not being hot enough at times. Kitchen staff were in-service to ensure proper food temperatures were maintained at the point of service. Interviews on 02/15/24 between 10:03 A.M. and 10:17 A.M., with Resident #83, #20, #73, and 47 revealed the food the facility served was not always warm enough. Observation on 02/15/24 at 12:12 P.M., of the tray line revealed chicken sandwiches, potato salad, and vegetable soup was being served. Oreo pie was also being served for dessert. Further observation continued as dietary staff plated the lunch meal from a steam table in the kitchen. As the tray line…
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 before2022-03-03 · 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, interview, and record review, the facility failed to ensure the high temperature dishwasher was maintained at appropriate temperatures to effectively wash and rinse dishes to help prevent food borne illnesses. This had the potential to affect 90 residents who receive meals daily from the kitchen, one resident, Resident #67 was ordered nothing by mouth. The facility census was 91. Findings include: Initial tour kitchen observation on 02/28/22 at 7:20 A.M. revealed the high temperature dishwasher wash temperature was 121 degrees Fahrenheit (F) and rinse temperature 176 degrees (F). The dishwasher was ran twice and temperatures were the same. Interview on 02/28/22 at 7:20 A.M. with Dietary Manager #900 confirmed the above temperatures and revealed the dishwasher was not getting up to the appropriate temperatures. Dietary Manager #900 reported the maintenance department was notified of the malfunction on 01/23/22. Review of facility maintenance repair request revealed a note on 01/23/22 reporting dishwasher rinse not hitting temp; on 02/08/22 dishwasher…
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 before2022-03-03 · 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 interview and record review, the facility failed to ensure weights were taken as ordered and meal intakes were recorded consistently for Residents #440 and Resident #445. This affected two residents (Resident #440 and Resident #445) of three residents reviewed for nutrition. Findings include: 1. Review of the medical record for Resident #445 revealed the resident was admitted on [DATE] with diagnoses including multiple fractures of ribs, right side, chronic obstructive pulmonary disorder (COPD), emphysema, heart failure, dementia, and pneumonia. Review of Resident #445's physician orders dated 02/03/22 and 02/24/22 revealed orders for weekly weights. Review of the care plan dated 02/04/22, revealed a care area for risk of altered nutrition/hydration with interventions dated 02/07/22 to monitor weight per protocol and monitor oral (P.O.) intake. Review of progress notes revealed Resident #445 was hospitalized from [DATE] until 02/24/22. Review of the Minimum Data Summary (MDS) 3.0 assessment dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2026-01-21 · tag F0732 — widespreadPost nurse staffing information every day.
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 ensure posted staffing information included an accurate count of certified nurse aides (CNAs) working within the facility. This had the potential to affect all residents residing within the facility. The facility census was 117. Findings include: Record review of the daily staffing posting for 01/13/26 revealed the posted staffing indicated there were 12 CNAs working from 7:00 A.M. to 7:00 P.M. Observation of the staffing levels on 01/13/26 at 9:34 A.M. revealed only 10 CNAs were working within the facility at that time. Record review of the facility staffing schedule for 01/13/26 revealed the facility scheduled eight CNAs to work from 7:00 A.M. to 7:00 P.M., one aide to work 7:00 A.M. to 3:00 P.M., one aide to work 3:00 P.M. to 7:00 P.M., and one aide to work 9:30 A.M. to 5:00 P.M. Six further CNAs were scheduled to work starting at 7:00 P.M. and two were scheduled to work starting at 11:00 P.M. Interview with Human Resources Director #597 on 01/13/26 at 9:51 A.M. confirmed the above findings. She said she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2026-01-21 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, the facility failed to maintain its garbage disposal area in a clean and sanitary condition. This had the potential to affect all residents in the facility. The facility census was 117. Findings include: Observation and interview of the facility's garbage disposal area with Dietary Manager (DM) #586 on 01/20/26 at 8:30 A.M. revealed significant food refuse and other trash all (used gloves, plastic utensils, dirt, leaves, and boxes of food) around the dumpster area. DM #586 verified the above findings at the time of discovery.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to O'NEILL HEALTHCARE — 6 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 | 2 of 5 | 4.2 | -2.2 vs chain |
| Health inspection | 2 of 5 | 3.7 | -1.7 vs chain |
| Staffing | 2 of 5 | 2.0 | ≈ chain avg |
| Quality measures | 4 of 5 | 4.8 | -0.8 vs chain |
The other 5 homes this chain runs (chain average 4.2★, 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 |
|---|---|---|---|---|
| CARLOW LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2012 |
| ONEILL, DEBORAH | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER | 13% | since 01/01/2011 |
| ONEILL, JOHN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER | 53% | since 01/01/2012 |
| ZISKA, DOREEN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 12% | since 01/01/2012 |
| TROCKLEY, KEVIN | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 01/18/2021 |
| O'NEILL MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/1999 |
CMS files one row per role, so the 10 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $3.4M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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 365264. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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