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Willow Ridge Of Mennonite Home Communities Of Ohio

101 Willow Ridge Drive, Bluffton, OH 45817 · Non profit - Church related · 20 certified beds · (419) 358-1015 Medicare & Medicaid certified

Call the home — (419) 358-1015 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Jul 2024Resident-funds citations (F0565, F0567)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has citations for mishandling residents’ money or property (F0565, F0567)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
139 Garau St · (419) 358-9010 · Call to confirm hours
Pharmacy
126 N Main St · (419) 369-4019 · Call to confirm hours
Grocery
117 S Main St · (419) 230-7606 · Call to confirm hours
Park
10740 Columbus Grove-Bluffton Rd · (419) 221-1232 · Typically dawn to dusk
Place of worship

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

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 4 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.5%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight0.0%6.2%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder7.4%0.2%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.5%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%30.1%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.0%3.2%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened2.0%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication18.9%25.5%18.9%typical
Long-stay residents with pressure ulcers0.0%3.4%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control19.9%21.4%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table31.9%8.8%17.1%worse

* 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.

0.14U.S. median 0.31
Therapy hours / resident / day
0.03hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 dischargenot 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

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

Staffing

0.85
RN hours/ resident / day
0.93
LPN hours/ resident / day
3.52
Aide hours/ resident / day
5.30
Total nurse hours/ resident / day
0.54
RN hoursweekends
32.3%
Total nursing turnover
80.0%
RN turnover

How full it usually is: this home is certified for 20 beds and averages 17.6 residents a day — about 88% occupied, or roughly 2 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 5.30 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.52 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 5.01 hrs/resident/day on weekends vs 5.41 on weekdays — 7% thinner on weekends. RN hours go from 0.97 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% is below 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

8
deficiencies at the latest standard inspection (2024-07-11)
7
at the previous standard inspection (2022-01-25)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · Gcited before2022-01-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to obtain and evaluate appropriate treatment, and removed an old dressing in a manner to prevent pain and tissue damage for one (#14) resident. This resulted in actual harm when Resident #14's ordered dressing was adhering to her open wound and was removed by the nurse without any interventions to loosen the dressing before removal. Resident #14 was noted to squeeze her eyes shut, grimace, tense her upper body, grab hold of the armrest with her hand, and pull her leg away when the dressing was removed. The wound was noted to be opened and actively bleeding following the immediate removal of the adhering dressing. Additionally, the facility failed to conduct a comprehensive wound assessment which including measurements of the wound for one (#14) resident out of one resident reviewed for wounds. The facility census was 18. Findings Include: Review of Resident #14's medical record revealed an admission…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-11 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews, the facility failed to ensure a thorough baseline care plan was created for one (Resident #172) of one reviewed for baseline care plans. The facility census was 20. Findings include: Review of the medical record for Resident #172 revealed an admission date of 07/01/24. The resident was admitted with diagnoses including aftercare following knee joint prosthesis, Parkinsonism, and hypertension. Review of the 07/01/24 admission skin assessment revealed documentation of a surgical wound with 31 staples and two sutures. Review of Resident #172's baseline care plan revealed no interventions or goals in place for the resident's surgical wound. Interview and observation on 07/08/24 at 10:47 A.M. revealed Resident #172 had thigh high compression hose on bilaterally. An Abdominal (ABD) pad was observed over his right knee. Upon questioning, Resident #172 stated he had right knee replacement surgery and was at the facility temporarily for therapy. Interview on 07/12/24 at 2:15 P.M. with the Director of Nursing verified there was no 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-11 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 record review and staff interview, the facility failed to ensure the advance directive code status in the Electronic Medical Record (EMR) matched the signed advanced directive form. This affected two (Resident #5 and #18) of three reviewed for advanced directives. The facility census was 20. Findings include: 1. Review of the medical record of Resident #5 revealed an admission date of 04/26/24 with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had severe cognitive impairment. Review of a physician order in the EMR dated 04/27/24 revealed Resident #5's advanced code status was Do Not Resuscitate - Comfort Care (DNR-CC). Review of the DNR Order Form dated 04/29/24 revealed Resident #5's advanced code status was Do Not Resuscitate - Comfort Care Arrest (DNR-CCA). Interview on 07/11/24 at 2:16 P.M. with the Director of Nursing (DON) confirmed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-11 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond 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 review of Self Reported Incidents (SRI), staff interviews, record review, and review of facility policy, the facility failed to complete thorough investigations related to resident-to-resident sexual abuse. This affected three residents (#16, #15, #7) of three reviewed for abuse. The facility census was 20. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 03/09/24. The resident was admitted with diagnoses including dementia, stroke, type two diabetes mellitus, depression, and hypertension. The resident remained at the facility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had intact cognition and required extensive one person assistance for toileting and supervision for eating, bed mobility and transfers. Review of the care plan revealed Resident #16 had a history of being drawn to various females by doting affection, asking for dates and wanting companionship. Interventions included to educate family members…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-11 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure a thorough comprehensive care plan was completed for two (Residents #19, #5) of three reviewed for care plans. The facility census was 20. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 11/15/23. The resident was admitted with diagnoses including unspecified dementia, anxiety, depression and senile degeneration of the brain. She was admitted to hospice on 05/16/24. The resident remained at the facility. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had severely impaired cognition. She required moderate assistance with eating, substantial assistance for bed mobility, and was dependent for toileting, hygiene, and transfers. Review of the care plan revealed no goals or interventions in place for hospice care. An interview on 07/11/24 at 2:15 P.M. with the Director of Nursing (DON) verified there was no hospice care plan for Resident #19…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-11 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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, staff interview, and policy review, the facility failed to ensure a comprehensive care plan was developed and implemented. This affected two (Residents #5 and #18) of two residents reviewed for care planning. The facility census was 20. Findings include: 1. Review of the medical record of Resident #5 revealed an admission date of 04/26/24 with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severe cognitive impairment and required set-up assistance for eating and oral hygiene, supervision assistance for ambulation, partial assistance for toileting hygiene, bathing, dressing, bed mobility, and transfers. Review of physician orders revealed an order dated 04/27/24 for an advance directive of Do Not Resuscitate - Comfort Care (DNR-CC), an order dated 04/27/24 for Apixaban (blood thinner) Oral Tablet 2.5 Milligram…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews, the facility failed to properly assess a surgical wound upon admission. This affected one (Resident #172) of one reviewed for wound assessments. The facility census was 20. Findings include: Review of the medical record for Resident #172 revealed an admission date of 07/01/24. The resident was admitted with diagnoses including aftercare following knee joint prosthesis, Parkinsonism, and hypertension. The resident remained at the facility. Review of the 07/01/24 admission skin assessment revealed documentation of a surgical wound with 31 staples and two sutures. There was no further description and no measurements of the surgical wound in the document. Interview and observation on 07/08/24 at 10:47 A.M. revealed Resident #172 had thigh high compression hose on bilaterally. An Abdominal (ABD) pad was observed over his right knee. Upon questioning, Resident #172 stated he had right knee replacement surgery and was at the facility temporarily for therapy. Interview on 07/10/24 at 1:59 P.M. with Registered Nurse (RN) #414 verified there were…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-11 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews, pharmacist interview, and policy review, the facility failed to ensure medications that should not be crushed were not crushed. This affected one (Resident #18) of one resident reviewed for medication administration. The facility census was 20. Findings include: Review of the medical record of Resident #18 revealed an admission date of 05/27/24 with diagnoses of fracture of other parts of pelvis, subsequent encounter for fracture with routine healing and essential (primary) hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #18 was independent for eating and required partial assistance for bed mobility and substantial assistance for toileting hygiene, bathing, dressing, transfers, and for wheelchair mobility over 150 feet. Review of physician orders revealed an order dated 06/13/24 for Aspirin Oral Tablet Delayed Release 81 Milligrams (mg) (Aspirin), give 81 mg by mouth one time…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, documentation, and staff interviews, the facility failed to follow their Legionnaires policy. This had the potential to affect all 20 residents at the facility. Findings include: Review of the undated facility policy, Legionnaires Policy, revealed the policy applied to all water systems which included, but not limited to shower heads and hoses, ice machines and infrequently used equipment, cold water would be heated to 140 degrees Fahrenheit by water heaters in each house and relevant procedures and record keeping related to the program would be kept, maintained and reviewed as necessary. Interview on 07/11/24 at 2:59 P.M. with Maintenance Director #509 revealed the provided policy and water testing by an outside testing facility for Legionella and intermittent room water temperatures were the only documentation available for Legionella. He verified in the seven months he had been employed, he did not test the temperature of the water heaters and there was no documentation the shower heads had been treated or when a resident room was empty,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-01-25 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview, the facility failed to prevent possible transmission of COVID-19 infection by failing to ensure the thermometer used for screening was properly disinfected between use by different persons. This had the potential to affect all 18 residents in the facility. The facility census was 18. Findings include: Observations on 01/18/22 through 01/22/22 revealed surveyors had to self screen upon entrance into the facility on a sheet of paper. The surveyors used a hand held thermometer to obtain their temperatures upon entrance. The facility staff did not disinfect thermometer between uses nor was there disinfectant available to disinfect the thermometer between uses. Interview on 01/19/22 at 2:40 P.M. with State Tested Nurse Aide (STNA) #430 verified she did not disinfect the thermometer after use.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-01-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and review the Dish Machine Temperature Log, the facility failed to ensure dishes were properly sanitized in the dishwashers in the 101 House. This affected all nine residents (#2, #6, #7, #10, #12, #13, #268, #269, and #270) who resided in the 101 House. The facility census was 18. Findings Include: Observation on 01/18/22 at 1:26 P.M. of State Tested Nursing Assistant (STNA) #415 found her running the dishwasher following the lunch meal in the 101 House. The dishwasher was noted to be a low temperature, chemical sanitization machine using chlorine for sanitation. The observed wash temperature was 120 degrees Fahrenheit (F) and rinse temperature of 129 degrees F. STNA #415 completed a test strip for chlorine sanitation levels and found the level were 25 parts per million (ppm). STNA #415 verified the proper level for sanitation was at least 50 ppm and dishwasher was not at the proper level of chlorine for sanitation. Observation on 01/18/22 at 1:38 P.M. of a second cycle of the dishwasher found the chemical sanitation level continued to be 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2022-01-25 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review, and staff interview, the facility failed to ensure the interdisciplinary team assessed a resident's ability to self administer and properly store medications. This affected one (#14) of six residents observed for medication administration. The facility census was 18. Findings include: Observation on 01/18/22 10:36 A.M. of Resident #14 revealed the resident had a bottle of Tums and a small cup of cough drops sitting on a bedside stand in her room. Review of Resident #14's medical record revealed an admission date of 11/27/19. Diagnoses included chronic obstructive pulmonary disease, psychosis, hallucinations, dementia, cognitive communication deficit, difficulty walking, unsteadiness on feet, and chronic kidney disease. Review of Resident #14's Minimum Data Set (MDS) assessment, dated 10/20/21, revealed the resident had severe cognitive impairment. Review of Resident #14's monthly physician orders dated January 2022 revealed no orders for Tums or cough drops. Review of Resident #14's current care plan revealed the care plan did not address…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-25 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure comprehensive care plans were developed for communication and significant weight loss. This affected three (#2, #9 and #14) out of eight residents reviewed for care plans. The facility census was 18. Findings include: 1. Review of Resident #14's medical record revealed an admission date of 11/27/19. Diagnoses included chronic obstructive pulmonary disease, psychosis, hallucinations, dementia, cognitive communication deficit, difficulty walking, unsteadiness on feet, and chronic kidney disease. Review of Resident #14's Minimum Data Set (MDS) assessment, dated 10/20/21, revealed the resident has severe cognitive impairment. The assessment also listed the resident as having moderate difficulty hearing and utilized a hearing aid. Review of Resident #14's current care plan did not address Resident #14's hearing loss and interventions to communicate with the resident. Additionally, observation on 01/18/22 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-25 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure resident care plans were revised. This affected three (#7, #9, #14) out of eight residents reviewed for care plan revisions. The facility census was 18. Findings include: 1. Review of Resident #14's medical record revealed an admission date of 11/27/19. Diagnoses included chronic obstructive pulmonary disease, psychosis, hallucinations, dementia, cognitive communication deficit, and chronic kidney disease. Review of Resident #14's Minimum Data Set (MDS) assessment, dated 10/20/21, revealed the resident had severe cognitive impairment. The assessment listed the resident as being at risk for pressure ulcers and having no pressure ulcers. Review of nurse's note for Resident #14 dated 12/28/21 revealed during morning care the resident was noted to have a racquetball size bruise to posterior aspect of the left knee. Review of Resident #14's weekly skin sweep dated 01/10/22…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-25 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure residents were provided ongoing range of motion (ROM). This affected one (#13) of two residents reviewed for limited range of motion. The facility census was 18. Finding Include: Review of Resident #13's medical record revealed an admission date of 09/26/18. Diagnoses included hemiplegia and hemiparesis, atrial fibrillation, hypertension, hypersomnia, muscle weakness, cerebral infarction, kidney failure, heart failure, abnormal posture, type II diabetes, and anemia. Review of Resident #13's Minimum Data Set (MDS) assessment, dated 10/13/21, revealed Resident #13 was cognitively intact. Resident #13 was totally dependent on staff for bed mobility, transfer, and toilet use. Resident #13 required extensive assistance with dressing and personal hygiene. Resident #13 was noted to have an upper extremity impairment on one side and and a lower extremity impairment on both sides. Resident #13 received passive range of motion three times during the seven calendar…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-05-02 · tag F0567 — failed to protect residents' money held by the home — pattern
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of resident funds accounts, staff interview, and review of the facility resident handbook, the facility failed to ensure residents had access to their resident funds at the facility. This affected two residents (#8 and #14) of four residents reviewed for resident funds accounts. The facility identified six residents (#6, #7, #8, #11, #13, and #14) with resident funds accounts. The facility census was 20. Findings include: 1. Review of resident funds accounts on 04/30/19 at 5:35 P.M., with [NAME] Specialist #147 revealed Resident #14 withdrew $15.00 from her resident funds account on 01/30/19. Review of the receipt for withdrawal revealed it was signed by two staff members, but not the resident. 2. Review of resident funds accounts on 04/30/19 at 5:35 P.M. with [NAME] Specialist #147 revealed Resident #8 withdrew $50.00 from her resident funds account on 01/04/19. Review of the receipt for withdrawal revealed it was signed by two staff members, but not the resident. Interview with [NAME] Specialist #147 during review of resident funds accounts revealed the residents…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-05-02 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and review of facility policy, the facility failed to ensure food was stored in a sanitary condition. The facility identified 10 (Residents #2,#3, #4, #7, #8, #10, #16, #17, #18 and #20) residents as receiving meals from the [NAME] House kitchen. The facility census was 20. Findings Include: Observation during the initial tour of the kitchen in the [NAME] House with State Tested Nurse Aide (STNA) #142 on 04/29/18 at 10:15 A.M. revealed one clear plastic bag half full of frozen shoestring french fries, one bag of half full frozen sweet potato french fries and one bag three quarters full of frozen turkey filets that had been previously opened. None of the three opened plastic bags contained labeling or dating of the items. Interview with STNA #142 on 04/29/19 at 10:15 A.M. during the observation confirmed the items had been opened and were silent for labeling and/or dating. Review of the facility provided undated policy titled, Date Marking revealed potentially hazardous…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-02 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was coded accurately for restorative nursing programs (RNP). This affected one (Resident #19) of one residents reviewed for limited range of motion. The facility identified 12 residents (#1, #4, #6, #8, #9, #10, #11, #13, #14, #16, #19, and #20) participating in a RNP. The facility census was 20. Findings include: Review of Resident #19's medical record revealed an admission date of 06/03/15. Medical diagnoses included athetoid cerebral palsy, generalized muscle weakness, involuntary movements, hypertension, dorsalgia, and asthma. Review of the resident's MDS assessment dated [DATE] revealed the resident had functional limitation in range of motion (ROM) in bilateral upper and lower extremities. He received RNP for passive ROM five out of seven days of the look back assessment period. The resident participated in active ROM four of seven days of the look back assessment period. Review…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-05-02 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 and staff interview, the facility failed to ensure a resident's care plan was revised to address a change in skin condition. This affected one (Resident #12) of one residents reviewed for pressure ulcers. The facility identified only one resident with a pressure ulcer. The facility census was 20. Findings include: Review of Resident #12's medical record revealed an admission date of 05/18/18. Medical diagnoses included generalized muscle weakness, malignant neoplasm of mouth, chronic kidney disease, chronic atrial fibrillation, abdominal aortic aneurysm, and gastrointestinal hemorrhage. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no impairment in cognition. He was identified as at risk for pressure ulcers. Review of the resident's wound documentation revealed two unstageable pressure ulcers developed on his right and left great toes on 04/09/19. Review of the resident's skin 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-05-02 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and resident and staff interview, the facility failed to ensure a resident's restorative nursing program (RNP) was implemented as planned. This affected one (Resident #19) of one residents reviewed for limited range of motion. The facility identified 12 residents (#1, #4, #6, #8, #9, #10, #11, #13, #14, #16, #19, and #20) participating in a RNP. The facility census was 20. Findings include: Review of Resident #19's medical record revealed an admission date of 06/03/15. Medical diagnoses included athetoid cerebral palsy, generalized muscle weakness, involuntary movements, hypertension, dorsalgia, and asthma. Review of the resident's physical therapy Discharge summary dated [DATE] revealed his prognosis to maintain current level of function was good with strong family support and consistent follow through. Recommendation was for a restorative program. Review of the resident's rehabilitation screens dated 12/24/18 and 03/20/19 revealed he did not demonstrate any changes since his…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of a facility procedure manual, the facility failed to ensure dietary assessments accurately reflected a resident's skin condition. This affected one (Resident #12) of one residents reviewed for pressure ulcers. The facility identified only one resident with a pressure ulcer. The facility census was 20. Findings include: Review of Resident #12's medical record revealed an admission date of 05/18/18. Medical diagnoses included generalized muscle weakness, malignant neoplasm of mouth, chronic kidney disease, chronic atrial fibrillation, abdominal aortic aneurysm, and gastrointestinal hemorrhage. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no impairment in cognition. He was identified as at risk for pressure ulcers and had moisture associated skin damage. Review of the resident's nutrition care plan dated 06/01/18 revealed the resident was at risk for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-02 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure accurate labeling of resident medications. This affected one (Resident # 1) of six residents observed for medication administration. The facility census was 20. Findings include: Review of Resident #1's medical record revealed an admission date of 11/26/18. Medical diagnoses included unspecified dementia with behavioral disturbance, paranoid personality disorder, anxiety disorder, chronic obstructive pulmonary disease, hypertension, insomnia, and major depressive disorder. Observation of medication administration on 05/01/19 at 8:02 A.M. for Resident #1 with Registered Nurse (RN) #124 revealed she administered 75 milligrams (mg) of Seroquel (antipsychotic) to the resident. Review of the Seroquel label revealed the resident was to receive 50 mg in the morning and 75 mg at night. The resident had two bottles of Seroquel labeled in this manner. Handwritten across the lid of the bottle was dose change. Continued review of the resident's medical record revealed the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-02 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    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, facility infection tracking logs, staff interview, and review of a facility policy, the facility failed to ensure a resident's prescribed antibiotic was in accordance with the Antibiotic Stewardship program. This affected one resident (#2) of one resident reviewed for urinary tract infections. The facility census was 20. Findings include: Medical record review for Resident #2 revealed an admission date of 08/27/18. Diagnoses included iron deficiency anemia, hypokalemia, transient cerebral ischemic attack, cardiac arrhythmia, myelodysplastic syndrome (deficient production of blood cells in bone marrow), anxiety disorder, epistaxis, cardiac pacemaker, major depressive disorder, muscle weakness, difficulty walking, heart failure, urinary tract infection site not specified, insomnia, anxiety disorder, diaphragmatic hernia, pulmonary fibrosis, age related osteoporosis, hypothyroidism, type two diabetes, and hyperlipidemia. Review of Resident #2's medication administration records…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
BRETHREN RETIREMENT COMMUNITYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 12/31/2024
ALLREAD, KARAIndividualCORPORATE DIRECTORsince 12/31/2024
ARNOLD, MATTHEWIndividualCORPORATE DIRECTORsince 12/31/2024
KELLER, LORIIndividualCORPORATE DIRECTORsince 12/31/2024
KEPLER, DAVIDIndividualCORPORATE DIRECTORsince 12/31/2024
MAURER, REBECCAIndividualCORPORATE DIRECTORsince 12/31/2024
NORTH, STEVENIndividualCORPORATE DIRECTORsince 12/31/2024
POLHAMUS, MARJORIEIndividualCORPORATE DIRECTORsince 12/31/2024
SHETLER, DAVIDIndividualCORPORATE DIRECTORsince 12/31/2024
SUBLER, JEFFIndividualCORPORATE DIRECTORsince 12/31/2024
WARNER, JOHNIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 12/31/2024
NICKLES, LANCEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/15/2024

CMS files one row per role, so the 15 rows in the source record cover these 12 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.

What families pay in OH

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366402. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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