Mennonite Memorial Home
410 W Elm Street, Bluffton, OH 45817 · Non profit - Church related · 60 certified beds · (419) 358-1015 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — 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 (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 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 improved from 2 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 | 12.8% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 2.6% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.3% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.6% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 30.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 2.1% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 8.8% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.6% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 17.4% | 25.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 96.2% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.0% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.0% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.1% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.2% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 47.2% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 29.4% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.6% | 12.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.21 | 1.73 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.69 | 1.80 | 1.80 | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
49.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 60 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 74.2% 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 31 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 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 49.8%CMS range 41.8–60.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.3%CMS range 6.4–13.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 74.2% | 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 | 67.7% | 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 | 54.8% | 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 | 57.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 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 | 7.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 3.8–12.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.88 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 54.5 residents a day — about 91% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.02 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 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 4.20 on weekdays — 15% thinner on weekends. RN hours go from 0.77 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.
- Potential for harm · Ecited before2025-06-03 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and review of facility policy, the facility failed to ensure residents were provided with assistance for activities of daily living (ADL's). This affected 10 (#10, #11, #12, #13, #14, #15, #16, #20, #21 and #22) residents residing on the secured dementia unit. The facility census was 58. Findings include: Review of medical record for Resident #10 revealed admission date of 04/21/25 with diagnoses including pneumonia, atrial fib and heart failure. The resident remained in the facility. Review of Resident #10's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. She required supervision for eating, max assist for toileting and moderate assistance for bed mobility and transfers. Review of medical record for Resident #11 revealed admission date of 09/24/19 with diagnoses including Parkinson's, dementia, stroke, and dysphagia. The resident remained at the facility. Review of Resident #11'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 · D2025-06-03 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to timely notify a resident's representative of change of condition in the resident. This affected one (#19) of three residents reviewed for change of condition. The facility census was 58. Findings included: Review of Resident #19's medical record revealed the resident was admitted on [DATE] with diagnosis of malignant of cardia, lymph, and lung and diabetes type two. Review of Resident #19 nursing note dated 04/23/25 at 5:20 A.M. revealed Resident #19 was hard to arouse, opens eyes to name but then closes eyes. Finger blood sugar was 150. At 5:23 A.M., nine-one-one (911) for hospital transportation was called, at 5:25 A.M. notification was made to the physician, at 5:26 A.M. emergency squad arrived, at 5:27 A.M. report was called to the hospital and at 5:38 A.M. squad left facility for route to hospital. Husband was not notified due to not having husband's contact information. Review of Resident #19's of nursing note date 04/23/25 at 12:44 P.M.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-18 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, the facility failed to ensure medications were not expired. This had the possibility to affect all 57 residents residing in the facility. The facility census was 57. Findings include: Observation at 10:50 A.M. of the large supply room with Licensed Practical Nurse (LPN) #498 revealed the following over-the-counter medications for residents: one bottle of fiber powder dated best by 3/24, one bottle of Calcium D 5 micrograms dated best by 6/24, one bottle of oyster calcium 500 milligrams (mg) dated best by 4/24 and three bottles dated best by 8/24, one bottle of melatonin 3 mg dated best by 10/24, and one bottle of acetaminophen liquid 500 mg in 15 milliliters dated best by 3/24. LPN #498 immediately verified the findings and removed the bottles from the room to dispose of them. The facility failed to produce a policy for medication storage.
- Potential for harm · Dcited before2024-11-18 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, the facility failed to ensure residents were treated with dignity during dining when Certified Nursing Assistance (CNA) #479 failed to sit while assisting Resident #50 to eat his lunch. This affected one resident (#50) of one needing assistance to eat. The facility census was 57. Findings include: Review of the medical record of Resident #50 revealed an admission date of 11/20/23. Resident #50 was severely cognitive impaired. Observation on 11/12/24 at 11:48 A.M. revealed CNA #479 provided Resident #50 with five coffee cups with thin consistency foods in them. CNA #479 picked up one cup and held the cup to Resident #50's lips and he drank from the cup. Resident #50 picked up a Kennedy cup with a straw and proceeded to drink from the straw. CNA #479 would walk away from Resident #50 to perform other tasks and would return to Resident #50 and pick up the cups and put them to his lips. At no point did CNA #479 sit to assist Resident #50 to eat his food. Interview on 11/12/24 at 12:00 P.M. with CNA #479 stated, Am I supposed to sit? CNA #479…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-18 · 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, review of the facility policy for care plans, and staff interview, the facility failed to have a complete care plan relating to a pressure ulcer. This affected one (Resident #34) out of two residents reviewed for pressure ulcer care plans. The current census is 57. Findings include: Review of the medical record for Resident #34 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #34 include dementia with Lewy bodies, diabetes type two, atrial fibrillation, and congestive heart failure. Review of Resident #34's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and had no pressure ulcers. Review of Resident #34's MDS significant change assessment dated [DATE] revealed the resident was documented as having one stage three pressure ulcer which was unhealed. Review of Resident #34's care plans dated 06/19/24 revealed there was no focus addressing the care and treatment of Resident #34's pressure ulcer 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 · D2024-11-18 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to develop a discharge summary which included a recapitulation of stay and the resident's final status. This affected one resident (#58) of one resident reviewed for discharge. The facility census was 57. Findings include: Review of Resident #58's medical record revealed an admission date of 08/14/24 and a discharge date of 09/09/24. Diagnoses included heart disease, dysphagia, cognitive communication, dementia, and syncope and collapse. Review of Resident #58's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight indicating Resident #58 was moderately cognitively impaired. Resident #58 required maximal assistance with eating, bathing, transfers, and parts of dressing. Resident #58 was dependent with toilet use, and parts of dressing. Resident #58 displayed verbal behavioral symptoms directed toward other one to three days during the review period.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-18 · 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 medical record review, observations, resident, staff and Nurse Practitioner (NP) #601 interviews, the facility failed to properly assess and treat pressure ulcers. This affected two (Residents #34 and #56) of two residents reviewed for pressure ulcers. The facility census was 58. Findings include: 1. Review of the medical record for Resident #34 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with Lewy bodies, diabetes type two, atrial fibrillation, and congestive heart failure. Review of Resident #34's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, no open wounds, and had no pressure ulcers. Review of Resident #34's care plans dated 06/19/24 revealed there was no focus areas addressing the care and treatment of Resident #34's pressure ulcer to the coccyx on the baseline care plans. Review of Resident #34's admission skin assessment dated [DATE] revealed the nurse documented an 'open lesion' to the coccyx,…
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 · D2024-11-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to put interventions in place in a timely manner to prevent weight loss. This affected one (Resident #55) of three reviewed for weight loss. The facility census was 57. Findings include: Review of the medical record of Resident #55 revealed an admission date of 09/07/24. Diagnoses included calculus of bile duct, encounter for surgical aftercare following surgery on the digestive system, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #09 had mild cognitive deficit. The assessment indicated no dental concerns and no swallowing or chewing difficulties. Review of the care plan dated 09/13/24 revealed a focus of increased nutrition/hydration risk related to diagnoses of calculus of bile duct in gallbladder, hypertension, history of pulmonary embolism, seborrheic dermatitis, long-term use of anticoagulants, iron deficiency anemia, and overactive bladder. A focus of at risk…
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 · D2024-11-18 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews, and review of the facility policy, the facility failed to ensure proper oversight of a resident receiving nutrition through enteral tube feed which led the resident experiencing a significant weight loss of seven-point five percent (7.5%) in six months. This affected one (#02) of two residents reviewed for tube feeding nutrition. The census was 57. Findings included: Review of medical record for Resident #02 revealed an admission date of 02/26/24. Diagnoses including cerebral palsy, dysphasia, aphasia, gastrostomy, feeding difficulties, abnormal posture, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 was severely cognitively impaired. The resident was dependent with eating. Further review revealed a weight loss of five percent or more in the last month, or a weight loss of 10 percent or more in the last six months. The resident utilized a feeding tube. Review of the physician's orders revealed 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 · Dcited before2024-11-18 · 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, staff interview, and review of facility policy, the facility failed to ensure residents had appropriate diagnosis to the support the use of an antipsychotic medication. This affected one resident (#261) of six residents reviewed for psychotropic medication use. The facility census was 57. Findings include: Review of Resident #261's medical record revealed an admission date of 11/04/24. Diagnoses included anxiety disorder, hearing loss, diverticulitis, and dysphagia. Review of Resident #261's Minimum Data Set (MDS) assessment dated [DATE] revealed an admission MDS was in progress. Review of Resident #261's care plan revised 11/06/24 revealed supports and interventions for forgetfulness, nutrition risk, history of wandering and exit seeking, self-care deficit, risk for pain, risk for falls, and use of antipsychotic medication related to anxiety. Review of Resident #261's physician orders revealed an order dated 11/06/24 for quetiapine fumarate (antipsychotic) 25 milligrams (mg) give…
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 · Dcited before2024-11-18 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure insulin was administered as ordered. This resulted in a significant medication error. This affected one (Resident #15) of four observed for medication administration. The facility census was 57. Findings include: Review of the medical record of Resident #15 revealed an admission date of 11/22/22. Diagnoses included diabetes mellitus. Review of the physician order dated 07/26/23 revealed Novolog insulin Aspart was to be administered as per sliding scale. If the blood glucose level was 201-300 inject two units subcutaneous. A second order dated 08/01/23 revealed to inject 15 units Novolog insulin Aspart subcutaneous with meals. Observation on 11/13/24 at 7:25 A.M. revealed Registered Nurse (RN) #457 obtained a blood glucose level from Resident #15. The reading was 273 milligrams per deciliter and RN #457 checked the order and discovered the amount of Novolog insulin to be administered would have been two units. RN #457 obtained the Novolog insulin and a syringe and drew up…
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 · D2024-11-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and policy review, the facility failed to ensure a glucometer device was disinfected between resident use. This had the potential to affect three (Residents #03, #12, and #15) identified by the facility as having blood glucose monitoring. The facility census was 57. Findings include: Observation on 11/13/24 at 7:25 A.M. revealed Registered Nurse (RN) #457 obtained a blood glucose reading on Resident #15 using a shared glucometer and used an alcohol prep pad to cleanse the device. Immediately following the cleansing, RN #457 verified the use of the alcohol prep to cleanse the device and stated, I suppose that is the wrong disinfection solution. RN #457 then looked through the medication cart and found no disinfection cloths. Interview on 11/13/24 at 7:27 A.M. with Director of Nursing revealed the solution to disinfect the glucometer should have been a Sani-Wipe disinfecting cloth, not alcohol. Review of the policy titled, Obtaining a Fingerstick Glucose Level, revised 10/11, revealed to ensure the glucose meter is cleaned and disinfected between…
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 before2024-04-15 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 facility census, review of the facility self-reported incidents (SRIs), review of facility investigations, and policy review, the facility failed to ensure residents were free from verbal abuse and mistreatment. This affected one (#32) of two residents reviewed for abuse and had the possibility to affect 31 (#14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43 and #44) residents residing on the hallway. The facility census was 53. Findings include: Review of the SRI dated 03/11/24, revealed State Tested Nurse Assistant (STNA) #101 left a note for the Director of Nursing (DON) indicating a concern about STNA #100's reaction to Resident #32's behaviors. STNA #101 had witnessed STNA #100 holding down Resident #32's arms/wrists and placed a paper towel over his mouth after Resident #32 had attempted to spit on her. STNA #101 reportedly intervened and instructed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-15 · tag F0609 — failed to report abuse allegations — patternTimely 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 medical record review, staff interview, review of facility census, review of the facility self-reported incidents (SRIs), review of facility investigations, and policy review, the facility failed to timely report an allegation of an incident of a staff member potentially verbally abusing and mistreating a resident to the Administrator and state agency. This affected one (#32) of two residents reviewed for abuse and had the possibility to affect 31 (#14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43 and #44) residents residing on the hallway. The facility census was 53. Findings include: Review of the SRI dated 03/11/24, revealed State Tested Nurse Assistant (STNA) #101 left a note for the Director of Nursing (DON) indicating a concern about STNA #100's reaction to Resident #32's behaviors. STNA #101 had witnessed STNA #100 holding down Resident #32's arms/wrists and placed a paper towel over his mouth after…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-15 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
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 facility census, review of the facility self-reported incidents (SRIs), review of facility investigations, and policy review, the facility failed to timely begin an investigation, complete a thorough investigation and provide protection to residents, when an allegation of a staff member potentially verbally abusing and mistreating a resident was made. This affected one (#32) of two residents reviewed for abuse and had the possibility to affect 31 (#14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43 and #44) residents residing on the hallway. The facility census was 53. Findings include: Review of the SRI dated 03/11/24, revealed State Tested Nurse Assistant (STNA) #101 left a note for the Director of Nursing (DON) indicating a concern about STNA #100's reaction to Resident #32's behaviors. STNA #101 had witnessed STNA #100 holding down Resident #32'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 · F2023-11-14 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility's posted nursing hours, review of licensure staffing tool, and staff interview, the facility failed to ensure there was a Registered Nurse (RN), working in the facility for 8 hours a day, 7 days a week. This has the potential to affect all 55 residents residing in the facility. The current census is 55. Findings include: Review of the facility's daily posted nursing hours for 10/28/23, 10/29/23, and 11/12/23 revealed there was no RN scheduled to work in the facility. Review of the licensure staffing tool dating from 11/07/23 to 11/13/23 revealed on 11/12/23 no hours for a RN, including the DON, were listed on the staffing tool. Interview on 11/14/23 at 1:40 P.M. with the Administrator verified there was no RN coverage for 10/28/23, 10/29/23, and 11/12/23. Per the Administrator the facility has used agency staffing but did not schedule any RNs for dates of 10/28/23, 10/29/23, and 11/12/23. The Administrator verified the DON was not working in the building on the dates missing the RN coverage. This deficiency represents non-compliance discovered during 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 before2023-09-21 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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, Self-Reported Incident (SRI) review, employee disciplinary review, staff interview, resident interview, in-service review and policy review, the facility failed to ensure a resident was free from verbal and physical abuse by a staff member. This affected one (#56) of three resident reviewed for potential abuse. The facility census was 56. Findings include: Review of medical record for Resident #56 revealed admission date of 11/17/22, with diagnoses including Parkinson's disease, stress incontinence, urinary incontinence, and difficulty in walking. Review of the Minimum Data Set (MDS) assessment, dated 07/08/23 revealed with a brief interview mental status (BIMS) score of 15 indicating cognitively intact. The resident required extensive two assist of one person for toileting and walk in room. The resident was frequently incontinent of urine and always…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-08 · 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 observation, staff interview and review of facility policy, the facility failed to ensure residents were cared for in a manner that promoted dignity. This affected two residents (#4 and #15) of thee reviewed for dignity. The facility census was 39. Findings include: 1. Review of Resident #4's medical record revealed an admission date of 02/26/20. Diagnosis included cerebral palsy, contractures of right shoulder, left hand and left knee, dysphagia, convulsions, and anxiety disorder. Review of Resident #4's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero, indicating Resident #4 was rarely or never understood. A Staff Assessment for Mental Status was completed and revealed Resident #4 had short and long term memory problems. Resident #4 was only able to recall staff names and faces. Resident #4 was not aware of the current season, location of her room, or that she was in a nursing home. Resident #4 was totally dependent on staff for all 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 · Dcited before2022-08-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, medical record review, and review of facility policy, the facility failed to assist a female resident with shaving facial hair. This affected one (Resident #2) of three residents reviewed for activities of daily living. The facility census was 39. Findings include: 1. Review of Resident #2's medical record revealed an admission date of 10/13/21. Diagnoses included dementia with behavioral disturbance, paranoid schizophrenia, cognitive communication deficit, and adult failure to thrive. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three, indicating Resident #2 was severely cognitively impaired. Resident #2 required supervision, set up only with personal hygiene. Resident #2 displayed no behaviors during the review period. Review of Resident #2's care plan revised 08/01/22 revealed the resident was at risk for impaired activities of daily living function due to cognition. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-08 · 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 record review, observation, staff interview, and review of facility policy, the facility failed to assess, document, measure, and complete accurate assessments for pressure ulcers. This affected one (Resident #245) out of three residents reviewed for pressure ulcers. The facility's census was 39. Findings include: Record review of Resident #245 revealed the resident was admitted to the facility on [DATE]. Resident #245 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses for Resident #245 included COVID-19, chronic kidney disease, obesity, atrial fibrillation, history of falls, stage II pressure ulcer of sacrum, pressure induced deep tissue damage to right heel, altered mental status, and dysphagia. Review of Resident #245's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had impaired cognition with one unstageable pressure ulcer and one deep tissue injury. Further review of Resident #245's medical record revealed a baseline care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-08 · 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
Based on observation, staff interview, review of manufacturers recommendations, and review of facility policy, the facility failed to ensure medications were administered without errors. This resulted in two medication errors out of 27 medication opportunities or a 7.4 percent (%) medication error rate. This affected one (Resident #28) out of eight residents observed for medication administration. Facility census was 39. Findings include: Observation on 08/03/22 at 4:15 P.M. revealed Licensed Practical Nurse (LPN) #575 was observed preparing medication to be administered to Resident #28. LPN #575 removed a Aspart Tempo insulin pen from the medication cart and dialed 15 units on the pen and placed a clean needle on the end of the pen. LPN #575 removed a Basaglar Kwikpen (insulin pen) from the medication cart and dialed 33 units into the pen and placed a clean needle on the end of the pen. She took both insulin pens into the resident's room and injected the insulin from both insulin pens into the resident's lower abdomen. Interview on 8/03/22 at 4:25 P.M. LPN #575 verified she did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-08 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, review of manufacturers recommendations, and review of facility policy, the facility failed to ensure staff primed an insulin pen prior to the administration of insulin, resulting in significant medication errors. This affected one (Resident #28) out of eight residents observed for medication administration. Facility census was 39. Findings include: Observation on 08/03/22 at 4:15 P.M. revealed Licensed Practical Nurse (LPN) #575 was observed preparing medication to be administered to Resident #28. LPN #575 removed a Aspart Tempo insulin pen from the medication cart and dialed 15 units on the pen and placed a clean needle on the end of the pen. LPN #575 removed a Basaglar Kwikpen (insulin pen) from the medication cart and dialed 33 units into the pen and placed a clean needle on the end of the pen. She took both insulin pens into the resident's room and injected the insulin from both insulin pens into the resident's lower abdomen. Interview on 8/03/22 at 4:25 P.M. LPN #575 verified she did not prime the needles with 2 units of insulin before…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-08 · 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 medical record review, staff interview, and review of facility policy, the facility failed to complete labs as ordered. This affected one (Resident #25) out of five residents reviewed for lab completion. The facility census was 39. Findings include: Review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including congestive heart failure, vascular dementia, dysphasia, paranoid personality, anxiety, psychotic with delusions, essential hypertension, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has short and long term memory loss. The resident displayed verbal and physical behaviors one to three days of the assessment period and received antipsychotic, antidepressant, and antianxiety medications. Review of the plan of care updated 07/20/22 revealed Resident #25 was receiving psychotropic medications for psychosis with delusions, anxiety and depression. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-08-29 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident and or representative were provided with written documentation upon transfer and/or discharge to the hospital. This affected two (#46, #48) of two residents reviewed for hospitalizations. The facility census was 47. Findings include : 1. Review of the medical record for Resident #46 revealed an admission date of 06/25/19. Diagnoses included pneumonia, multiple sclerosis, chronic respiratory failure and severe sepsis with septic shock. Review of the nurses notes dated 07/21/19 and 07/30/19 revealed Resident #46 was sent to the emergency room. Review of the medical record revealed no documentation of a notice of the transfer was given to the resident and or representative. Interview with the Administrator on 08/28/19 at 2:25 P.M. verified they did not provide a reason for transfer notice to Resident # 46 for either of his discharges to the hospital on [DATE] or 07/30/19. The Administrator…
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 before2019-08-29 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, and facility policy review, the facility failed to ensure a care plan was revised following a resident elopement. This affected one resident (#14) of twelve residents reviewed for care plans. The facility census was 47. Findings Include: Review of Resident #14's medical record revealed an admission date of 07/06/17. Diagnoses included vascular dementia with behavioral disturbance, paranoid personality disorder, anxiety disorder, restlessness and agitation, repeated falls, and depressive disorder. Review of Resident #14's Minimum Data Set (MDS) assessment, dated 06/26/19, revealed the resident to have severe cognitive impairment. The resident was assessed to wander/elopement alarm daily. Review of Resident #14's nurse's note dated 08/22/19 revealed the resident was found outside of a fenced area in her wheelchair. Review of Resident #14's care plan on 08/26/19 revealed the care plan did not have a revision to include an intervention after an elopement that occurred on 08/22/19. Interview on 08/27/19 at 10:32 A.M. with Registered Nurse…
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 · D2019-08-29 · 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
Based on medical record review, observation, interview and review of facility policy, the facility failed to ensure oxygen tubing was dated for one (#23) of one resident reviewed for respiratory care. The facility identified 11 residents utilizing oxygen therapy. The facility census was 47. Findings include: Review of the medical record for Resident #23 revealed an admission date of 03/02/17. Diagnoses included Parkinson's disease, major depressive disorder with severe psychotic symptoms, osteoarthritis, anxiety disorder, type two diabetes mellitus, hypertension, atrial fibrillation, chronic kidney disease-stage three, vascular dementia with behaviors, paranoid schizophrenia, athersclerotic heart disease, gastroesophageal reflux disease, and hypothyroidism. Review of the Minimum Data Set (MDS) assessment, dated 07/10/19, revealed Resident #23 had intact cognition. Observation on 08/26/19 at 1:27 P.M. revealed an oxygen concentrator present in Resident #23's room. The nasal cannula tubing connected to the oxygen concentrator was not dated. Interview and observation on 08/27/19 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-08-29 · 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
Based on medical record review, staff interview, review of pharmacy recommendations, and review of facility policy, the facility failed to ensure an as needed psychotropic medication had a specific duration of use beyond the 14 days for one (#5) of five reviewed for unnecessary medications. The census was 47. Findings include: Review of the medical record for Resident #5 revealed an admission date of 03/19/19. Diagnoses included generalized anxiety disorder. Review of the physician's orders dated 03/22/19 revealed an order for the antianxiety medication Ativan 0.5 milligram (mg), give 0.5 mg by mouth every six hours as needed (prn) for anxiety, up to three times a day. Review of pharmacy recommendation dated 04/04/19 for Resident #5 revealed the resident was receiving Ativan 0.5 mg every six hours prn. CMS regulations stipulate the to use prn medication beyond 14 days, a prescriber must believe the order should be extended, and document the clinical rationale and specific duration. The duration of use did not have any documentation on the order. This form was signed by the physician…
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 before2019-08-29 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure medications were properly stored/disposed of after a resident refusal. This affected one (#22) of five residents observed during medication administration. The facility census was 47. Findings include: Review of Resident #22's medical record revealed an admission date of 10/18/12. Diagnoses included dementia with behavioral disturbance, anxiety disorder, dysphagia, paranoid personality, restlessness, and agitation. Review of Resident #22's Minimum Data Set (MDS) assessment, dated 07/10/19, revealed the resident had severe cognitive impairment. Review of Resident #22's Medication Administration Record (MAR) dated August 2019 revealed the following medications were to be administered in the morning, duloxetine 60 milligrams (mg) orally, Synthroid 50 micrograms (mcg) orally, Buspar 20 mg orally, Haldol 0.25 milliliters (ml) orally, Tylenol 650 mg orally, Ativan 1 mg orally, and Tramadol 50 mg orally. Observation on 08/28/19 at 8:10 A.M. of medication administration…
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 · C2024-11-18 · tag F0584 — failed to keep a safe, clean, comfortable home — widespreadHonor 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 — the official record, unedited, may be distressing
Based on observation, staff interview, and review of facility policy, the facility failed to ensure over head paging was used only in case of emergency. This had the potential to to affect all residents in the facility. The facility census was 57. Findings include: Observation on 11/12/24 at approximately 11:00 A.M. found an overhead paging system being utilized requesting maintenance staff to go to the second floor. Observation on 11/18/24 at 9:44 A.M. found the overhead paging system loudly playing what sounded like a phone being on hold. The sound grew increasingly louder. Interview on 11/18/24 at 9:47 A.M. with Administration Staff (AS) #436 verified the overhead paging system was loudly projecting a telephone on hold. Review of the facility policy titled, Overhead Paging Policy, dated 05/29/13 revealed overhead paging would only be allowed in case of an emergency.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BRETHREN RETIREMENT COMMUNITY | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 12/31/2024 |
| ALLREAD, KARA | Individual | CORPORATE DIRECTOR | — | since 12/31/2024 |
| ARNOLD, MATTHEW | Individual | CORPORATE DIRECTOR | — | since 12/31/2024 |
| KELLER, LORI | Individual | CORPORATE DIRECTOR | — | since 12/31/2024 |
| KEPLER, DAVID | Individual | CORPORATE DIRECTOR | — | since 12/31/2024 |
| MAURER, REBECCA | Individual | CORPORATE DIRECTOR | — | since 12/31/2024 |
| NORTH, STEVEN | Individual | CORPORATE DIRECTOR | — | since 12/31/2024 |
| POLHAMUS, MARJORIE | Individual | CORPORATE DIRECTOR | — | since 12/31/2024 |
| SHETLER, DAVID | Individual | CORPORATE DIRECTOR | — | since 12/31/2024 |
| SUBLER, JEFF | Individual | CORPORATE DIRECTOR | — | since 12/31/2024 |
| WARNER, JOHN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 12/31/2024 |
| NICKLES, LANCE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/15/2024 |
| WOODRUFF, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/31/2024 |
CMS files one row per role, so the 17 rows in the source record cover these 13 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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 366144. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-18, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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.