Trinity Community
3218 Indian Ripple Road, Beavercreek, OH 45440 · Non profit - Corporation · 95 certified beds · (937) 426-8481 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
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $9,932 in federal fines (most recent 2024-04-18)
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 | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.1% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 6.6% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.4% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 8.2% | 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 | 4.3% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.9% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 16.9% | 25.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.3% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.5% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.8% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 94.2% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.0% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 11.9% | 12.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.78 | 1.73 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.05 | 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.
63.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 172 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 41.7% 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 72 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% 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 | 63.7%CMS range 56.8–71.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.6%CMS range 5.8–11.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 41.7% | 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 | 41.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 51.4% | 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 | 99.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.0% | 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 | 1.0% | 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 | 7.8%CMS range 4.2–13.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 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 95 beds and averages 84.0 residents a day — about 88% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.92 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 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 3.58 hrs/resident/day on weekends vs 4.05 on weekdays — 12% thinner on weekends. RN hours go from 0.56 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% 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 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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2024-04-18 · 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 staff interview, record review, facility protocol review, and hospital record review, the facility failed to ensure residents received treatment and care in accordance with professional standards when they failed to hold blood pressure medications and notify the doctor of a low blood pressure for Resident #77. This resulted in actual harm when Resident #77 was hospitalized with diagnoses of hypotension, acute kidney injury, and altered mental status. Resident #77 had an elevated Blood Urea Nitrogen (BUN) level of 110 milligrams per deciliter (mg/dl), and elevated creatinine level of 3.22 mg/dl, and a hospital emergency room triage blood pressure of 80/36 millimeters of mercury (mmHg). This affected one (Resident #77) of three residents reviewed for hospitalization. The facility census was 79. Findings include: Record review of Resident #77 revealed an admission date of 03/02/24 with an admission to the hospital on [DATE] and a readmission to the facility on [DATE]. Resident #77 had pertinent diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-03 · 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, staff interview, and policy review, the facility failed to store, prepare, distribute, and serve foods in accordance with professional standards for food service safety. This had the potential to affect 79 residents in the facility. The facility identified two residents (21 and #137) who did not receive food from the kitchen. The facility census was 81. Findings include: Observation of the kitchen's reach in coolers on 03/31/25 at 8:25 A.M. revealed the following: a. a plastic tub of yogurt, opened and partially used, with no open date b. a bag of spinach with an open date of 03/20 c. two packages of lunch meat, opened and not dated d. a bag of hotdogs, opened, not sealed, not dated e. a plastic container of cheese slices, not labeled, not dated f. a bag of garlic cloves, opened, partially used, not dated g. a plastic container of chickpea patties, not labeled, not dated, and the cover was not properly affixed to the container Interview at the time of the observation, [NAME] #357 verified the yogurt was not dated, the spinach was outdated, lunch meat was 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 · F2025-04-03 · 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 ensure trash cans in the kitchen food preparation areas were covered. This had the potential to affect 79 residents in the facility. The facility identified two residents (#21 and #137) who did not receive food from the kitchen. The facility census was 81. Findings include: Observation on 03/31/25 at 8:30 A.M. revealed a trash can in the food preparation area by the stove was not covered. Interview at the same time, [NAME] #357 verified the trash can did not have a lid. [NAME] #357 stated she looked for a lid and was not able to locate one. Observation on 04/02/25 at 11:47 A.M., the trash can in the food preparation area remain uncovered. Review of the facility policy titled, Food Safety-Director of Food and Nutrition Services' Responsibilities, dated 2019 revealed the director of food and nutrition services assures sanitary conditions are maintained in food storage, preparation, and serving areas and proper waste disposal methods.
- Potential for harm · D2025-04-03 · 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 medical record review and staff interview, the facility failed to refer residents for Pre-admission Screening and Resident Review (PASARR) level two services after a significant mental health change. This affected one (56) of the six residents reviewed for PASARR. The census was 81. Findings include: Review of the medical record for Resident #56, revealed the resident was admitted to the facility on [DATE]. Her diagnoses included but were not limited to bipolar disorder, psychotic disorder with delusions, and mood disorder. Review of the Brief Interview for Mental Status (BIMS) dated 02/18/25 for Resident #56 revealed a score of 12, indicating the resident was moderately cognitively intact. Review of Resident #56's medical records revealed the following mental health diagnoses were not included in her current PASARR application: bipolar disorder (02/27/25), Mood Disorder (09/06/24), and Psychotic Disorder with Delusions (09/06/24). There was no documented evidence that an initial or significant change…
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 · D2025-04-03 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure baseline care plans were developed within 48 hours of admission. This affected three (#29, #54, and #139) of the 12 residents reviewed for baseline care plans. The facility census was 81. Findings include: 1. Review of the medical record of Resident #29 revealed an admission date of 02/27/25. Diagnoses included acute on chronic congestive heart failure (CHF), acute and chronic respiratory failure with hypoxia and hypercapnia, type 2 diabetes mellitus, morbid obesity, prostate cancer, and hypothyroidism. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #29 had intact cognition. The resident required supervision for eating, and was dependent on staff for toileting, bathing, dressing, bed mobility, and transfers. Review of the care plans revealed a baseline care plan was initiated on 03/11/25. Interview on 04/01/25 at 2:57 P.M., Licensed Practical Nurse (LPN) #417 verified Resident #29…
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 · D2025-04-03 · 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 record review, staff interview, and policy review, the facility failed to ensure meal intakes were monitored and recorded. This affected one (#77) of the seven residents reviewed for nutrition. The facility census was 81. Findings include: Review of the medical record for Resident #77, revealed an admission date of 01/16/24. Diagnoses included but were not limited to metabolic encephalopathy, urinary tract infection, and Coronavirus (COVID-19). Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #77 had severe cognition evidenced by a Brief Interview for Mental Status (BIMS) of 00. The resident was dependent on staff for activities of daily living (ADLs). Review of the documentation for Nutrition Amount Eaten from 03/21/25 through 04/02/25 for Resident #77, revealed the dinner time meal intakes were not documented for dinner with the exception of 03/25/2025. Interview on 04/02/25 at 10:30 AM with the Dietician Tech (DT) #345 confirmed Resident #77's dinner…
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 · D2025-04-03 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review the facility failed to maintain accurate records for supplemental orders. This had the potential to affect one (77) of the seven residents reviewed for resident orders. The census was 81. Findings Include: Review of the medical record for Resident #77, revealed an admission date of 01/16/24. Diagnoses included but were not limited to metabolic encephalopathy, urinary tract infection, and Coronavirus (COVID-19). Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #77 had severe cognition evidenced by a Brief Interview for Mental Status (BIMS) of 00. The resident was dependent on staff for activities of daily living (ADLs). Review of physician orders for Resident #77 dated 01/18/25, revealed the resident was ordered Ensure (supplement) with meals. Review of the weights documented for Resident #77 revealed a weight change of 5.37 percent (%). A documented weight on 02/13/25 revealed her weight to be 201.00 lbs. and on 03/10/25…
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 · D2023-08-21 · 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 interview, medical record review, and policy review, the facility failed to ensure residents received medications as ordered. This affected one (#20) of four residents reviewed for medications. The facility census was 79. Findings include: Review of the medical record for Resident #20 revealed an admission date of 04/11/19. Diagnoses included unspecified Alzheimer's disease, pseudobulbar effect, and unspecified anxiety disorder. Review of Resident #20's physician orders revealed an order dated 08/07/22 for the narcotic pain medication oxycodone five (5) milligrams (mg), to give 2.5 mg by mouth twice daily for knee pain. Review of a progress noted dated 06/30/23 revealed Licensed Practical Nurse (LPN) #23 administered oxycodone 5 mg instead of oxycodone 2.5 mg to Resident #20. Interview on 08/21/23 at 1:59 P.M., LPN #23 verified she had made a medication error on 06/30/23 when she gave Resident #20 a double dose of oxycodone by mistake. LPN #23 stated she thought she was administering Resident #20's 5:00 P.M. dose of oxycodone 2.5 mg and 6:00 P.M. dose of the antianxiety…
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 · D2023-08-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review, the facility failed to ensure that medications were stored properly in medication carts. This affect one (#65) of eleven residents on the D-Hall with active prescriptions for the pain medication Tylenol 500 milligram (mg) tablets. The facility census was 79. Findings include: Review of the medical record revealed Resident #65 admitted to the facility on [DATE] and had primary diagnosis of unspecified rheumatoid arthritis. Review of Resident #65's medical record revealed a physician order dated 01/18/23 for the pain medication acetaminophen (Tylenol) 500 mg, one tablet by mouth three times daily for pain. Observation on 08/21/2023 from 8:48 A.M. to 8:51 A.M. revealed, in the top drawer of the D-Hall medication cart, a large plastic drinking cup labeled Tyle 500 with marker on the outside of the cup. Observed inside the cup was an unspecified, but numerous, quantity of round white tablets, and the tablets were marked with M2A4 57344. Licensed Practical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-04-25 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review the facility failed to offer residents influenza and pneumococcal immunizations. This affected five residents (#17, #29, #78, #330, and #339) of seven residents reviewed for immunizations. The facility census was 79. Findings include: 1. Review of Resident #17's medical record revealed an admission date of 03/18/22. Diagnosis included chronic kidney disease, encephalopathy, and peripheral vascular disease. Further review of Resident #17's medical record revealed no evidence the resident was offered a pneumonia or influenza vaccine. Review of the influenza and pneumonia vaccine section of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] was coded as not assessed. 2. Review of Resident #29's medical record revealed an admission date of 03/02/22. Diagnosis included neoplasm of the colon, acute kidney injury, and intellectual disability. Further review of Resident #29's medical record revealed no evidence the resident was offered 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 · D2022-04-25 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, observation and policy review, the facility failed to ensure residents were provided dignity when a resident was called a feed. This affected one resident (#25) of 18 residents reviewed. The facility identified 17 residents who were dependent for eating. The facility census was 79. Findings include: Review of the medical record for Resident #25 revealed an admission date of 01/17/20. Diagnoses included vascular dementia without behavioral disturbance, scoliosis, chronic pain, anemia, underweight, body mass index (BMI) 19.9 or less, adjustment disorder with mixed anxiety and depressed mood, malaise, muscle weakness, and dysphagia oropharyngeal phase. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had impaired cognition. There were no documented behaviors. The resident required limited assistance of one staff member for eating. Review of the plan of care dated 03/03/22 revealed the resident had an Activity of Daily…
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 19 citations
- Potential for harm · D2022-04-25 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 review, staff interview and policy review, the facility failed to ensure an Advanced Directive was signed by the physician. This affected one resident (#67) of one resident reviewed for Advanced Directives of 18 sampled. The facility identified 33 residents who had an Advanced Directive. The facility census was 79. Findings included: Review of the medical record for Resident #67 revealed an admission dated of [DATE]. Diagnoses included Alzheimer's Disease, heart failure, renal failure, and malnutrition. Review of the physician orders dated [DATE] revealed Resident #67 was a Do Not Resuscitate Comfort Care (DNRCC). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #67 was moderately cognitively impaired. Review of the advanced directive for Resident #67 revealed the directive was a DNRCC and the paperwork had not been signed or dated by the physician. Interview with the Registered Nurse (RN) #100 on [DATE] at 11:15 A.M., verified the advanced directive wasn't signed…
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 before2022-04-25 · 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 medical record review, staff and resident interview, observation and policy review, the facility failed to ensure care plans were updated. This affected two residents (#18 and #46) of 18 residents reviewed for care plans. The facility census was 79. Findings include: 1. Review of the medical record for Resident #18 revealed an initial admission date of 08/09/21 and a re-admission date of 08/13/21. Diagnoses included Dementia without behavioral disturbance, Chronic Obstructive Pulmonary Disease (COPD), and the need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #18 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 12 out of 15 (moderate impairment). Her behaviors included disorganized thinking and rejection of care. The resident required extensive assistance of one to two staff members for bed mobility, transfers, locomotion on and off the unit, dressing, personal hygiene, and toilet use. Further…
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 before2022-04-25 · 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 medical record review, staff interview, and review of the hospice agreement the facility failed to ensure residents who received hospice had current detailed and completed hospice medical records. This affected one resident (#25) of two residents reviewed for hospice services. The facility census was 79. Findings include: Review of the medical record for Resident #25 revealed an admission date of 01/17/20. Diagnoses included vascular dementia without behavioral disturbance, Scoliosis, chronic pain, anemia, underweight, body mass index (BMI) 19.9 or less, bilateral unspecified hearing loss, age-related osteoporosis without current pathological fracture, bilateral primary osteoarthritis of the knee, dysphagia oropharyngeal phase, and presence of left artificial hip joint. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/22/22, revealed the Resident #25 had impaired cognition. There were no documented behaviors. The resident required limited assistance of one staff member for eating and extensive assistance of one staff member for all other activities 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.
- Potential for harm · D2022-04-25 · 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 medical record review, staff and resident interview, observation, and policy review the facility failed to perform incontinence care per the facility policy/procedure. This affected two residents (#18 and #50) of three residents reviewed for incontinence care. The facility census was 79. Findings include: 1. Review of the medical record for Resident #18 revealed an initial admission date of 08/09/21 and a re-admission date of 08/13/21. Diagnoses included dementia without behavioral disturbance, Chronic Obstructive Pulmonary Disease (COPD), and the need for assistance with personal care. Review of the bowel and bladder assessment dated [DATE], 11/08/21, and 03/25/22 revealed the resident was able to feel the urge sensation for a bowel movement but was incontinent of bladder and bowel. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/28/22, revealed the Resident #18 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 12 out of 15 (moderate impairment). Her…
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 · D2022-04-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, observation and policy review, the facility failed to administer oxygen per orders and failed to properly store oxygen tubing/masks. This affected three residents (#25, #35 and #50) of 10 residents who used oxygen in the facility. The facility census was 79. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 01/17/20. Diagnoses included vascular dementia without behavioral disturbance, Scoliosis, chronic pain, anemia, underweight, body mass index (BMI) 19.9 or less, bilateral unspecified hearing loss, age-related osteoporosis without current pathological fracture, bilateral primary osteoarthritis of the knee and presence of left artificial hip joint. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #25 had impaired cognition. There were no documented behaviors. The resident required limited assistance of one staff member for eating and extensive assistance of one…
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 · D2022-04-25 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, observation, review of the pharmacy recommendations, review of an email correspondence and policy review the facility failed to timely address pharmacy recommendations. This affected two residents (#35 and #34) of five residents reviewed for unnecessary medications. The facility census was 79. Findings include: 1. Review of the medical record for Resident #35 revealed an initial admission date of 05/19/21 and a re-admission date of 07/23/21. Diagnoses included acute and chronic respiratory failure with hypoxia and hypercapnia, metabolic encephalopathy, Chronic Obstructive Pulmonary Disease (COPD), chronic congestive heart failure (CHF), overactive bladder, major depressive disorder, spina bifida, type II Diabetes Mellitus (DM2), Stage III Chronic Kidney Disease (CKD III), hyperlipidemia, iron deficiency anemia, restless legs syndrome, fibromyalgia, hypothyroidism, gastro-esophageal reflux disease (GERD), chronic pain syndrome, history of transient ischemic attack…
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 · D2022-04-25 · 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, staff and resident interview, observation and policy review the facility failed to ensure residents were provided physician ordered adaptive devices for eating. This affected two residents (#25 and #58) two residents reviewed for devices of 18 residents reviewed. The facility census was 79. Findings include: 1. Review of Resident #58's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included Parkinson's Disease, dementia with behavioral disturbances, bipolar disorder, major depressive and anxiety disorders, lobular carcinoma in the left breast, abnormality of gait, need for assistance with personal care, history of falls, and muscle weakness. Review of the quarterly Minimal Data Set (MDS) dated [DATE] revealed Resident #58 was cognitively intact. She required extensive one to two person assistance for all activities of daily living (ADL) except eating and she was supervision, set up help only. Review of the care plan dated 04/09/22 revealed a plan in…
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 · D2022-04-25 · 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 medical record review, staff interview, observations, and policy review the facility failed to perform hand hygiene before and after care, failed to wear gloves when handling soiled linen, failed to properly dispose of soiled linens and a soiled adult brief. This affected three residents (#25, #18, and #50) of 18 residents sampled. In addition, the facility failed to ensure isolation precautions were in place for a resident who required contact precaution. This affected one resident (#50) of two residents reviewed for isolation precautions. The facility census was 79. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 01/17/20. Diagnoses included vascular dementia without behavioral disturbance, Scoliosis, chronic pain, anemia, underweight, body mass index (BMI) 19.9 or less, bilateral unspecified hearing loss, age-related osteoporosis without current pathological fracture, bilateral primary osteoarthritis of the knee, and presence of left artificial hip…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-02-28 · 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 medical record review, staff interview, and facility policy review. the facility failed to timely revise the plan of care for five residents (#48, #49, #59, #61, and #433) of 18 care plans reviewed. The facility census was 82. Findings include: 1. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, Parkinson's disease, hypertension (HTN), major depression, and functional quadriplegia. Review of the plan of care (POC) target date of 01/28/19 revealed she had problems and goals to include activities of daily living (ADLs), pain, incontinence, skin break down, side effects of antidepressant medications, anticoagulant therapy, diuretic therapy, and HTN. The problems, goals, and interventions had not been updated or revised with the last MDS quarterly assessment. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed she had intact cognition, no mood issues, however one to three days she yelled, screamed 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 · D2019-02-28 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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, observations, staff and resident interviews, the facility failed to ensure an assessment was correct regarding the dental status for one resident (#48) of one reviewed for dental status. The facility census was 82. Findings included: 1. Review of the medical record for Resident #48 revealed an admission date of 08/31/18. Diagnoses included displaced intertrochanteric fracture of the right femur, chronic obstructive pulmonary disease, and Alzheimer's disease. Review of Resident #48's oral assessment dated [DATE] revealed the resident to have upper and lower dentures. There was no answer marked for the questions on whether the dentures fit properly, or could the resident take them in and out. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had moderate cognitive impairment. The resident was noted to not have ill-fitting dentures. Review of Resident #48's care plan dated 02/18/19 revealed the resident was care plan revealed 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 · D2019-02-28 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical review, open medical record review, staff interview, review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) guidelines, and facility policy review, the facility failed to timely complete MDS assessments within the required time frame. This affected two residents (#5 and #3) of 20 residents reviewed for MDS accuracy and timeliness of assessments. The facility census was 82. Findings include: 1. Review of medical record for Resident #5 revealed an admission date of 01/27/12 with diagnoses including Alzheimer's, dementia, and hypertension. She passed away at facility on 12/27/18. Review of Resident #5's MDS assessments revealed no discharge MDS was completed. Her last MDS was a quarterly assessment was dated 10/17/18. Review of the MDS 3.0 RAI guidelines revealed the completion date for the death in facility MDS is to be completed seven days after the date of death . Interview on 02/26/19 at 2:29 P.M., with Licensed Practical Nurse (LPN) #320 verified the discharge MDS…
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 · D2019-02-28 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) guidelines, and facility policy review, the facility failed to timely submit MDS assessments within the required time frame. This affected one resident (#3) out of six residents reviewed for MDS timeliness of submission. The facility census was 82. Findings include: Review of medical record for Resident #3 revealed an admission date of 10/09/18 with diagnoses including anemia, diabetes mellitus, and hypertension. She was discharged to hospital on [DATE] and readmitted to facility on 01/25/19. Review of Resident #3's quarterly MDS assessment dated [DATE] revealed it was signed as completed by the Registered Nurse (RN) on 01/29/19 and other sections of the MDS were not completed until 02/20/19. The MDS was not yet submitted and per RAI guidelines was to be submitted by 02/12/19. Review of Resident #3's discharge MDS dated [DATE] revealed it was completed on 02/20/19 and not yet submitted.…
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 · D2019-02-28 · tag F0642 — isolatedEnsure a qualified health professional conducts resident assessments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) guidelines, and facility policy review, the facility failed to ensure the Registered Nurse (RN) coordination of assessments and failed to ensure a RN signed and certified the MDS's were complete. This affected two residents ( #3 and #48) of six residents reviewed for MDS accuracy and RN signature. The facility census was 82. Findings include: 1. Review of medical record for Resident #3 revealed an admission date of 10/09/18 with diagnoses including anemia, diabetes mellitus, and hypertension. Review of quarterly MDS assessment dated [DATE] revealed the latest sections signed as completed by a licensed practical nurse (LPN) was 02/20/19, there were sections of the MDS also signed off by a therapist on 02/15/19 and social services on 02/01/19. The signature of the RN assessment coordinator verified assessment completion was 01/29/19 before sections were completed. 2. Review of 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 · Dcited before2019-02-28 · 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, observations, staff interview, resident interview, and review of assignment sheets, the facility failed to timely implement physician orders. This affected one resident (#75) of 21 resident reviewed for implementing physician orders. The facility census was 82. Findings include: Review of the medical record revealed Resident #75 was admitted to the facility on [DATE]. Diagnoses included acute diastolic heart failure, edema, chronic kidney disease stage three, abnormal weight gain, syncope with collapse, fall with fracture right lower extremity prior to admission, and localized edema. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident had intact cognition, and required extensive assistance of staff for bed mobility, transfer and toileting due to non weight bearing status of the right lower extremity. Review of the physician orders (PO) dated 02/18/19 revealed TED hose (anti-embolism stockings) were to be on Resident #75 in the morning 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 · D2019-02-28 · 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
Based on medical record review, staff interview, and facility policy review, the facility failed to investigate a resident's fall. This affected one resident (#59) of one resident reviewed for falls. The facility census was 82. Findings include: Review of medical record for Resident #59 revealed an admission date of 7/14/15 with diagnoses including Alzheimer's disease and major depression. Review of the Minimum Data Set (MDS) assessment completed on 01/09/19 revealed the resident had severe cognitive impairment. Review of Resident #59's nurse's progress note dated 01/20/19 revealed at 4:45 A.M., the resident was found on the floor in another resident's room. Resident #59 denied any pain or discomfort. Licensed Practical Nurse (LPN) # 220 assessed Resident #59 and found no injuries. There was no evidence the facility completed a fall investigation of the fall. On 02/27/19 at 4:06 P.M., interview with the Director of Nursing (DON) revealed she received notification by email of Resident #59 being found on the floor of another resident's room. She confirmed the facility did not do an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-02-28 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interview, resident interview, and review of the facility policy, the facility failed to ensure ongoing dialysis communication between the dialysis and the facility was maintained for one resident (#27) of one reviewed for dialysis. The facility census was 82. Findings include: Review of the medical record for Resident #27 revealed an admission date of 01/30/19 with a readmission date of 02/13/19. Diagnoses included end stage renal disease (ESRD), dependence on renal dialysis, and type two diabetes. Review of the five-day Minimum Data Set (MDS) assessment from the resident's previous admission, revealed Resident #27 had moderate cognitive impairment. Further review revealed the resident was on hemodialysis. Review of the care plan for Resident #27 dated 02/13/19, revealed the resident utilized hemodialysis related to renal failure. Interventions included but not limited to check and change dressing daily, access site, document assessment of the resident upon…
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 · D2019-02-28 · 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, observations, staff interview, and facility policy review, the facility failed to adequately monitor a resident's behaviors who was taking an anti-psychotic medication. This affected one resident (#50) of seven reviewed for unnecessary medications. The facility census was 82. Findings include: Review of the medical record revealed Resident #50 was admitted to the facility on [DATE]. Diagnoses included dementia with behaviors, anxiety, abnormal weight loss, sarcopenia, and Alzheimer's disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had impaired cognition. She had behaviors such as wandering, screaming, smearing bodily wastes, and disrobing. Review of the plan of care dated 02/16/19 revealed Resident #50 had mood problems, anxiety and was resistive to care. The resident would spit into tissues, spit on the floor, resist eating, remove clothing, and was at risk for drowsiness, fatigue and slowed reflexes. Interventions…
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 · D2019-02-28 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a resident's (#63)ordered as needed anti-anxiety medication was reviewed every 14 days. The facility further failed to ensure a resident (#59) who was ordered an anti-psychotic medication had an appropriate diagnoses for the use of the medication. This affected two residents (#63 and #59) of seven reviewed for unnecessary medications. The facility census was 82. Findings include: 1. Review of medical record for Resident #63 revealed admission date of 04/13/17 with diagnoses including adjustment disorder with anxiety, dementia with Lewy bodies, and kidney failure. Review of the most recent Minimum Data Set (MDS) assessment revealed the resident intact cognition. Review of Resident #63's December 2018 physician's orders revealed an order for Ativan, 0.5 milligrams (mg), every 12 hours, as needed for anxiety. Review of the Medication Administration Record (MAR) from 12/12/19 to 2/28/19 revealed Resident #63 received Ativan 18 times.…
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 · D2019-02-28 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, staff interview, and facility policy review, the facility failed to ensure lab test ordered were completed as ordered by the physician. This affected one resident (#433) of one resident reviewed for lab orders. The facility census was 82. Findings include: Review of the closed medical record revealed Resident #433 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbances, a mechanical heart valve, chronic kidney disease stage four, and diabetes. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #433 had impaired cognition, and took an anticoagulant (blood thinner) seven days. Review of the plan of care dated 01/14/19 revealed Resident #433 was on anticoagulant therapy and would be free from adverse reactions related to anticoagulant use. Interventions included laboratory values as ordered, monitor for bleeding, and avoid foods high in Vitamin K (a vitamin which caused thicker…
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
$9,932 in federal fines across 1 penalty.
- $9,932 — penalty dated 2024-04-18
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 UNITED CHURCH HOMES — 9 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 | 3.9 | -0.9 vs chain |
| Health inspection | 3 of 5 | 3.3 | -0.3 vs chain |
| Staffing | 3 of 5 | 3.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 8 homes this chain runs (chain average 3.9★, 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 |
|---|---|---|---|---|
| UNITED CHURCH HOMES, INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 04/01/2000 |
| BAILEY, PETER | Individual | CORPORATE DIRECTOR | — | since 06/01/2024 |
| BATES, TREVOR | Individual | CORPORATE DIRECTOR | — | since 02/01/2017 |
| BENJAMIN, PAMELA | Individual | CORPORATE DIRECTOR | — | since 06/01/2021 |
| BLACK, GEOFFREY | Individual | CORPORATE DIRECTOR | — | since 06/01/2016 |
| D'AGOSTINO, JOANNA | Individual | CORPORATE DIRECTOR | — | since 06/01/2024 |
| GRAHAM, GEORGE | Individual | CORPORATE DIRECTOR | — | since 06/01/2025 |
| GUESS, JAMES | Individual | CORPORATE DIRECTOR | — | since 06/01/2021 |
| HAWES-SAUNDERS, RO NITA | Individual | CORPORATE DIRECTOR | — | since 02/01/2024 |
| HENRY, JAMES | Individual | CORPORATE DIRECTOR | — | since 12/31/2014 |
| JAMES, JILL | Individual | CORPORATE DIRECTOR | — | since 06/01/2025 |
| LONG-HIGGINS, DAVID | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| SANDMAN, ROBERT | Individual | CORPORATE DIRECTOR | — | since 06/01/2025 |
| ULRICH, KARL | Individual | CORPORATE DIRECTOR | — | since 06/01/2016 |
| WILLIAMS, STEPHANIE | Individual | CORPORATE DIRECTOR | — | since 06/01/2014 |
| WINFREY, LAPEARL | Individual | CORPORATE DIRECTOR | — | since 06/01/2020 |
| NADERHOFF, JUDITH | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2026 |
| YOUNG, KENNETH | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/07/2025 |
| BILLS, ASHLEY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/26/2022 |
| BOLLINGER, NATHAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/31/2023 |
| BROWN, DALE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/12/2012 |
| BRUBAKER, TAMRA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/19/2022 |
| DURBIN, DEBRA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/15/2022 |
| EUSANIO, VINCENT | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/31/2025 |
| FARRELL, LAURA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/07/2026 |
| FAULKNER, MICHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2026 |
| HURWITZ, GLORIA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/07/2013 |
| KELLEY, MEGAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/2023 |
| KLENZMAN, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/15/2022 |
| LONG-HIGGINS, ELIZABETH | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/02/2022 |
| MAGHES, MICHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/24/2025 |
| MILLER, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/04/2017 |
| MULLIKIN, JUDY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/19/1986 |
| SLUTZ, SCOTT | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2016 |
| SPITZNAGEL, TERESA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/15/2022 |
| STACEY, AMANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2026 |
| SZEWCZYK, MELODY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/22/1986 |
| THORP-SWEITZER, KIMBERLY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/15/1994 |
| TILLMAN, MICHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/21/2020 |
| VAUGHAN, CORRYE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/20/2004 |
| VAUGHN, RICHARD | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/06/2006 |
| VENKATESH, LATHA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/30/2026 |
| WARREN, ASHLEY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2026 |
CMS files one row per role, so the 49 rows in the source record cover these 43 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $784K 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 365777. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-03, 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.