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Wood Haven Health Care Senior Living & Rehab

1965 E Gypsy Lane Rd, Bowling Green, OH 43402 · Government - County · 93 certified beds · (419) 353-8411 Medicare & Medicaid certified

Call the home — (419) 353-8411 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 2025Behavioral-health or dementia-care citation — no harm found (F0740)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
  • 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
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1069 Klotz Rd · (419) 728-0110 · Call to confirm hours
Pharmacy
131 W Gypsy Lane Rd · (419) 352-3396 · Call to confirm hours
Grocery
131 W Gypsy Lane Rd · (419) 309-0822 · Call to confirm hours
Park
1014 S Maple St · (419) 353-1897 · Typically dawn to dusk
Place of worship
749 S Wintergarden Rd · (419) 352-0417

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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 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 held steady at 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.

Overall rating4★
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 increased2.4%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight6.9%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.2%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms13.0%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.2%3.2%3.3%worse
Long-stay residents whose ability to walk worsened5.6%6.1%16.1%typical for the state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication22.7%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine98.6%94.5%95.3%typical
Long-stay residents with pressure ulcers3.4%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control27.2%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table5.0%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine63.3%75.6%79.4%worse
Short-stay residents rehospitalized after admission18.3%24.9%22.6%better
Short-stay residents with an outpatient ER visit5.4%12.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.291.731.67better
Long-stay outpatient ER visits per 1,000 resident days1.601.801.80better

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.

56.5% 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 117 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.5%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
53.7%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 53.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 41 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 SNF56.5%CMS range 48.9–63.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.6–16.710.7%Oct 2022–Sep 2024no 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 discharge53.7%56.6%Oct 2024–Sep 2025CMS 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 discharge51.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge53.7%50.0%Oct 2024–Sep 2025CMS 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 identified97.8%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay2.2%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened6.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.0%CMS range 3.2–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 2022–Sep 2024CMS 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

0.49
RN hours/ resident / day
1.02
LPN hours/ resident / day
2.20
Aide hours/ resident / day
3.71
Total nurse hours/ resident / day
0.29
RN hoursweekends
48.8%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 93 beds and averages 82.1 residents a day — about 88% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 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 3.23 hrs/resident/day on weekends vs 3.91 on weekdays — 17% thinner on weekends. RN hours go from 0.57 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2026-04-09)
12
at the previous standard inspection (2023-03-30)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

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.

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 · E2026-04-09 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, and policy review the facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects, and adverse effects. This affected five (#1, #11, #12, #44, and #62) of five residents reviewed for unnecessary medications. The facility census was 83. Findings include:1. Review of Resident #1's medical record revealed an admission date of 09/18/26. Diagnoses included end stage renal disease, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, type two diabetes mellitus, and major depressive disorder. Review of resident #1's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. Additionally, Resident #1 took antianxiety, antidepressant, diuretic, opioid, and hypoglycemic medications. Review of Resident #1's care plan dated 08/28/25 revealed Resident #1 was at risk for side effects of psychotropic medication used for 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 · E2026-04-09 · tag F0835 — failed to run the facility competently — pattern
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review, the facility failed to ensure routine monitoring was implemented for mechanical lift slings and stand assist devices in the facility. This had the potential to affect 31 (#3, #15, #23, #34, #74, #83, #30, #43, #80, #9, #31, #63, #29, #12, #54, #61, #72, #25 #11, #13, #17, #32, #40, #44, #47, #51, #56, #61, #72, #78 and #81) that the facility identified as requiring the use of a mechanical lift slings or stand assist devices. The facility census was 83.Findings include:Observation on 04/07/26 at 12:59 P.M. of a mechanical lift transfer from wheelchair to bed for Resident #83 completed by Certified Nurse Aide (CNA) #372 and CNA #390 revealed the sling used was worn and no longer had a tag attached. Concurrent interview with CNA #390 verified the sling utilized to transfer Resident #83 was worn and no longer had a tag attached to the sling. Further interview with CNA #372 and #390 revealed they were not aware of who was responsible for monitoring 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-09 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, resident interview, review of manufacturer's instructions, and policy review, the facility failed to ensure mechanical lift slings were monitored and inspected per the manufacturer's instructions. This affected six (#83, #34, #15, #74, #23 and #3) and had the potential to affect 13 other residents (#11, #13, #17, #32, #40, #44, #47, #51, #56, #61, #72, #78 and #81) who the facility identified as requiring the use of a mechanical lift with slings for transfer. The facility census was 83.Findings include:1. Review of Resident #83's medical record revealed an admission date of 07/14/23. Diagnoses included muscle weakness, dementia, hypertension, major depressive disorder, and polyneuropathy.Review of Resident #83's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 had a memory problem. Furthermore, Resident #83 required substantial or maximum assistance for chair to bed, bed to chair, and toilet transfers.Review of Resident #83'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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-09 · 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 medical record review, staff interview, and policy review, the facility failed to ensure a thorough investigation was completed when an allegation of verbal abuse and neglect was reported. This affected one (#95) of one resident reviewed for verbal abuse and neglect. The facility census was 83.Findings include:Review of medical record for Resident #95 revealed admission date of [DATE]. Diagnoses included type two diabetes mellitus with diabetic polyneuropathy, depression, stroke and dysphasia. The resident was admitted to hospice on [DATE] and died in the facility on [DATE].Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #95 had a Brief Interview Mental Status (BIMS) score of five indicating severely impaired cognition. Furthermore, Resident #95 required set up for eating, moderate assistance with toileting hygiene, bed transfers and transfers.Interview on [DATE] at 2:16 P.M. with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing…

    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 · D2026-04-09 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy the facility failed to complete a Preadmission Screening and Resident Review (PASRR) level II following a new diagnosis of schizophrenia. This affected one (#12) of one resident reviewed for PASRR level II. The facility census was 83.Findings include:Review of the medical record for Resident #12 revealed an admission date of 01/31/24. Diagnoses included Alzheimer's disease, dementia, schizophrenia, psychotic disorder with hallucinations, anxiety, adult failure to thrive, and breast cancer.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #12 revealed the resident had severe cognitive impairment, had a diagnosis of schizophrenia, and was not receiving any anti-psychotic medications.Review of the care plan initiated 06/25 for Resident #12 revealed she was care planned for schizophrenia. Interventions included to administer medications as ordered, monitor for changes in the resident's mood, observe…

    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 before2026-04-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of manufacturer guidelines, the facility failed to maintain and inspect resident transfer equipment to ensure safe transfers. This affected one (#80) of three residents reviewed for falls. The facility census was 83.Findings include:Review of medical record for Resident #80 revealed admission date of 04/04/23. The resident was admitted with type II diabetes mellitus, anxiety, anemia, and depression. The quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of 8 indicating impaired cognition. Resident #80 required supervision with eating, maximum assistance with toileting hygiene, bed mobility and was dependent upon staff with transfers.Review of the care plan dated 09/26/25 for Resident #80 revealed the resident had an activity of daily living self-care performance deficit related to diabetes mellitus, neuropathy and a mood disorder. Interventions included for the resident to use the mechanical…

    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 · D2026-04-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, staff interview, and review of the facility policy, the facility failed to administer oxygen at the correct rate. This affected one resident (#15) reviewed for oxygen. The facility identified 11 residents (#1, #2, #13, #15, #19, #21, #40 #50, #57, #65, and #84) that required the use of oxygen. The facility census was 83.Findings include:Review of the medical record for Resident #15 revealed an admission date of 04/28/21. Diagnoses included chronic respiratory failure, shortness of breath, pulmonary hypertension, and congestive heart failure.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 revealed she was cognitively intact and required the use of oxygen therapy.Review of the care plan revised 04/26 for Resident #15 revealed she was care planned for respiratory status and difficulty breathing related to asthma, chronic respiratory failure, and congestive heart failure with intervention in place to administer oxygen as…

    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 · D2025-12-08 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview, the facility failed to ensure accurate assessments were completed. This affected one (#65) of three residents reviewed for assessments. The facility census was 76.Findings include:Review of the medical record for Resident #65 revealed an admission date of 02/20/25 with diagnoses including, but not limited to, psychotic disorder with delusions, Parkinson's disease, anxiety, depression, dementia, and neurocognitive disorder with Lewy bodies.Review of the Nursing admission Assessment completed on 02/20/25 revealed the resident had natural teeth, with missing teeth and no dentures.Review of the Oral Status and Dental assessment completed on 02/21/25 revealed the resident had natural teeth, with missing teeth and no dentures.Review of the Oral Status and Dental assessment completed on 05/22/25 revealed the resident had natural teeth, with missing teeth and no dentures.Review of the Minimum Data Set (MDS) assessment, dated 11/04/25, revealed the resident had severe cognitive impairment. The assessment indicated Resident #65 had no broken…

    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 · D2025-12-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 Review of the medical record for Resident #19 revealed an admission date of 07/12/25 with diagnoses including, but not limited, to seborrheic dermatitis, pressure ulcer of sacral region stage three (full thickness to fat), pressure ulcer of right buttock stage three, pressure ulcer of left buttock stage three, and paraplegia.Review of the Minimum Data Set (MDS) assessment, dated 12/02/25, revealed the resident was cognitively intact. Resident #19 had two stage three pressure ulcers that were present on admission.Review of the care plan dated 07/16/25 revealed the resident had two stage three pressure ulcers upon admission and dermatitis/fungal infection related to disease processes- paraplegic, non-compliant with care and getting up out of bed. Interventions included administer treatments as ordered, low air loss (LAL) alternating pressure mattress, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, and type of tissue and exudate.Review of the weekly…

    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 · D2025-01-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 record review, resident interview, staff interview and review of facility policy the facility failed to ensure residents were free from abuse. This affected one resident (#10) of two residents reviewed for abuse. The facility census was 71. Findings include: Review of Resident #10's medical record revealed an admission date of 12/30/23. Diagnoses included schizophrenia, psychosis, and congestive heart failure. Review of Resident #10's annual MDS dated [DATE] revealed he had an intact cognition. No behaviors were documented. Review of Resident #10's most recent care plan revealed he had a history of trauma that carried negative effects. Interventions included to encourage the resident to express feelings, concerns, and thoughts in a safe space and identify items that lessen the effect of trauma and provide comfort. Review of Resident #10's medical record revealed a nurse's note dated 12/08/24 informing Licensed Practical Nurse (LPN) # 230 Resident #10 was in an activity with another male resident who…

    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
Show the remaining 19 citations
  • Potential for harm · D2025-01-06 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 staff interviews, resident interviews, record review, and facility policy review revealed facility staff failed to report an allegation of abuse. This affected two residents (#10 and #11) of two residents reviewed for abuse. The facility census was 71. Findings include: Review of Resident #11's medical record revealed an admission date of 04/04/23. Diagnoses included intellectual disabilities, encephalopathy, and altered mental status. Review of Resident #11's quarterly Minimum Data Set (MDS) revealed the resident had a moderate decline in cognition. The resident had no behaviors documented. Review of Resident #11's behavior note dated 12/08/24 revealed the resident was in the activity room and displayed inappropriate actions and required redirection from staff back to his room. The actions were not specified. Review of Resident #11's physician note dated 12/10/24 revealed the resident had developed more aggressive behaviors since being off Abilify (antipsychotic). Review of Resident #11's behavior note…

    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 · D2025-01-06 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, nurse practitioner interview, family interview, and review of facility policy revealed the facility failed to follow documented medication orders in resident records. This affected one (#84) resident of three residents reviewed for medication orders. The facility census was 71. Findings included: Review of Former Resident (FR) #84's medical record revealed an admission date of 11/26/24. Diagnoses included thyroid cancer, urinary tract infection, and cystitis. Review of FR #84's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an intact cognition. Review of FR #84's care plan revealed the resident had a temporary placement in the facility and planned on returning home after the completion of therapies. Review of FR #84's nursing note dated 11/22/24 revealed the resident was admitted from a local hospital and was alert, oriented and able to make needs known. Review of FR #84's Medication Administration Record (MAR) dated 11/22/24 revealed the resident…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record review, review of the facility's incident reports, and review of the facility's policies, the facility failed to complete thorough investigations into wandering/elopement and fall incidents. This affected one (#11) of two residents reviewed for elopement and one (#11) of three residents reviewed for falls. The facility census was 76. Findings include: Review of the medical record for Resident #11 revealed an admission date of 11/29/23. Diagnoses included dementia, anxiety, and transient ischemic attack. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/14/24, revealed Resident #11 had impaired cognition, used a walker and wheelchair, and required substantial/maximal assistance for bed mobility and transfers. Resident #11 demonstrated wandering behaviors four to six days during the look-back period. Resident #11 had two or more falls without injury since the previous assessment/admission. 1. Review of the Exit Seeking Assessment completed upon admission, dated 11/29/23, revealed no score or level of risk for exit seeking behaviors…

    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 · F2023-03-30 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident, resident representative, and staff interviews, record reviews, review of resident council notes, review of staff schedules, and review of facility policies, the facility failed to ensure there was sufficient nursing staff to meet the resident care needs. This affected three residents (#10, #34, and #45), and had the potential to affect all 74 residents residing in the facility. Findings include: Review of the Facility Assessment Tool, updated 01/05/23, revealed the competent staffing support to provide care for the resident population every day and during emergency range from three to nine direct care nurse aides per shift and two to four direct care nurses per shift. Review of the facility's Resident Census and Conditions of Residents dated 03/27/23 revealed 65 of 74 residents required staff assistance with transferring, 71 of 74 residents required assistance with toileting, and 74 residents required staff assistance with bathing. 1. Review of Resident #45's medical record…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-03-30 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 of the facility policy, the facility failed to ensure foods were properly sealed, labeled, and dated in the freezer and failed to maintain the refrigerator and freezer in a sanitary condition. This had the potential to affect all 74 residents identified by the facility as reviewing food from the kitchen. The facility census was 74. Findings include: Observations on 03/27/23 at 9:00 A.M. in the upright freezer revealed there were opened and unlabeled foods including a bag of grilled chicken breast, bag of chicken tenders. There was an opened, unlabeled, and undated food items which included bag of chocolate chip cookies and bag of french fries. Interview with Dining Services Manager (DSM) #559 at the time of the observation verified the opened, unlabeled and undated food items. Observations on 03/27/23 at 9:10 A.M. in the walk-in freezer revealed there was frost build up at the bottom of the fan unit inside the walk-in freezer with a nearby pipe with water that dripped and froze into two separate icicles hanging down. Interview with…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-30 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interviews, and review of the facility policy, the facility failed to ensure call lights were answered timely and the residents requiring assistance had access to call lights. This affected four (#10, #22, #54, and #60) of four residents reviewed for call lights. The facility census was 74. Findings include: 1. Review of Resident #10's medical record revealed Resident #10 was admitted on [DATE]. Diagnoses included spastic hemiplegic cerebral palsy, mixed hyperlipidemia, pure hypercholesterolemia, essential (primary) hypertension, and unspecified convulsions. Review of the Minimum Data Set (MDS) assessment, dated 01/02/23, revealed Resident #10 was cognitively intact. Resident #10 required extensive one person assistance with bed mobility, transfers, walking in room, walking in corridor, dressing, toilet use, and personal hygiene. Resident #10 was always continent of bowel and bladder. Review of the care plan, updated 02/08/19, revealed Resident #10…

    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 · D2023-03-30 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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, resident interview, resident representative interview ,staff interview, and review of the facility policy, the facility failed to ensure residents received their choice of showers or bed baths. This affected two (#34 and #54) of two residents reviewed for choices. The facility census was 74. Findings include: 1. Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included chronic kidney disease stage three, dementia moderate with psychotic disturbance, anxiety disorder, restlessness and agitation, and muscle weakness. Review of the care plan, dated 08/22/22, revealed Resident #34 required assistance with activities of daily living and preferred his showers two days per week and as needed on first shift. Review of the Minimum Data Set (MDS) assessment, dated 02/03/23, revealed Resident #34 was moderately cognitively impaired. Resident #34 was totally dependent on staff for bathing. Review of the facility's shower/whirlpool/bed bath documentation,…

    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 · D2023-03-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff and resident interviews, and review of facility policy, the facility failed implement the facility policy for self-medication administration for Resident #76 and further failed to obtain physician orders for the medications being self-administered by Resident #76. This affected one (Resident #76) of three residents reviewed for choices. The facility census was 74. Findings include: Review of the medical record for Resident #76 revealed an admission date of 03/06/23. Diagnoses included a displaced intertrochanteric fracture of left femur, and macular degeneration. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 was cognitively intact. Further review of the medical record from 03/06/23 to 03/27/23 revealed there was no medication self-administration for Resident #76. There was no physician order for Resident #76 to self-administer his medications until 03/27/23. Observation on 03/27/23 at 9:24 A.M. revealed a bottle of over 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-30 · 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, staff and resident interview, and review of the facility policy, the facility failed to develop a comprehensive care plan to address a resident's psychosocial needs. This affected one (Resident #37) of four residents reviewed for care planning. The facility census was 74. Findings include: Review of the medical record for Resident #37 revealed an admission date of 01/20/23. Diagnoses included acute on chronic heart failure, chronic kidney disease, and peripheral vascular disease. Review of the physician order dated 01/20/23 revealed an order for psychiatric services for evaluation or follow up. services. Review of the baseline care plan for Resident #37 dated 01/24/23 revealed it was silent for psychological or behavioral health needs. Review of the comprehensive Minimum Date Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was cognitively intact, had experienced little interest or pleasure in doing things for the last 12 to 14 days, felt down or depressed two to six days and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-30 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, resident representative and staff interview, and review of the facility policy, the facility failed to ensure a resident received activities upon the preference of the resident and choices of activities. This affected one (Resident #54) of one resident reviewed for activities. The facility census was 74. Findings include: Review of the medical record revealed Resident #54 was admitted on [DATE]. Diagnoses included Alzheimer's disease, anxiety disorder, epilepsy, major depressive disorder recurrent, restlessness and agitation, and dementia without behavioral disturbance psychotic disturbance. Review of the Minimum Data Set (MDS) assessment, dated 02/14/23, revealed Resident #54 was unable to complete the interview. Resident #54 required extensive two-person assistance with bed mobility and transfers and required total dependence from staff with locomotion on and off the unit and personal hygiene. Review of the care plan, dated 05/18/22, revealed Resident #54 was 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-30 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff and resident interviews, and review of the facility policy, the facility failed to provide care and services to assist a resident to maintain hearing devices. This affected one resident (Resident #55) of four residents reviewed for vision and hearing. The facility census was 74. Findings include: Review of the medical record for Resident #55 revealed an admission date of 04/16/21. Diagnoses included Alzheimer's disease, cataract extraction right eye and left eye (status post on 07/26/21), anxiety disorder, dementia, and hearing loss. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 was cognitively impaired and had adequate hearing with the use of a hearing aid device. Speech was clear and the resident understands and was understood. Review of the care plan revealed Resident #55 had a hearing impairment affecting the resident's ability to communicate. Interventions included hearing to be evaluated upon request and nursing…

    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 · Dcited before2023-03-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident and staff interview, and review of the facility policy, the facility failed to provide timely assistance to prevent a fall with injury and failed to complete a thorough fall investigation. This affected one (Resident #45) of five residents reviewed for falls. The facility census was 74. Findings include: Review of Resident #45's medical record revealed the resident was admitted on [DATE]. Diagnoses included anxiety disorder, repeated falls, and general weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively intact. Resident #45 required extensive assistance from staff with transferring and toilet use and required supervision for walking in the room and walking on and off the unit. Review of Resident #45's plan of care, undated, revealed Resident #45 was at risk for falls related to unsteady gait and history of falls. The goal was for Resident #45 not to sustain an injury from falls. Interventions included were to…

    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 · D2023-03-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the care and management for an indwelling urinary catheter for Resident #40. This affected one (Resident #40) of three resident reviewed for having an indwelling urinary catheter. The facility identified 10 residents with indwelling or external catheters. The facility census was 74. Findings include: Review of the medical record for Resident #40 revealed an admission date of 02/02/23. Diagnoses included a cerebral infarct on 02/10/23, obstruction and reflux uropathy, hydronephrosis with renal and urethral calculous and a bladder neck obstruction. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired. Resident #40 was always continent of bowel and required the use of an indwelling urinary catheter. Review of the care plan dated 02/06/23 revealed an indwelling urinary catheter due to the inability to empty bladder…

    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 · D2023-03-30 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff and resident interview, and review of the facility policy, the facility failed to ensure a resident received mental health services and psychiatric services per physician orders to attain the highest practicable mental well-being. This affected one resident (Resident #37) of one resident reviewed for mental health. The facility census was 74. Findings include: Review of the medical record for Resident #37 revealed an admission date of 01/20/23. Diagnoses included acute on chronic heart failure, chronic kidney disease, and peripheral vascular disease. Review of the physician order dated 01/20/23 revealed an order for psychiatric services for evaluation or follow up services. There was no evidence in the medical record this was completed from 01/20/23 to 03/27/23. Review of the social service admission assessment dated [DATE] revealed Resident #37 lived in an apartment and used a walker and wheelchair and required a hospital admission on [DATE] due to edema and congestive…

    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 · D2023-03-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and policy review, the facility failed to ensure medications were dated when opened and medications were used within the expiration date, and failed to store medications in a locked compartment. This affected two of three medications carts reviewed and one of two medication storage rooms. This affected one (Resident #26) of 21 residents observed for the physical environment. The facility census was 74. Findings include: 1. Observation on 03/28/23 at 7:56 A.M. of Northwest two medication cart revealed there were five eye drop containers without an open date. Brimonidine tartrate solution 0.15%, Dorzolamide HCL-Timolol Mal PF solution 2-0.5 %, Refresh Optive Advanced Ophthalmic solution 0.5-1-0.5%, Latanoprost ophthalmic emulsion 0.005% and Xalatan Solution 0.005%. Interview on 03/28/23 at 7:59 A.M. with Licensed Practical Nurse (LPN) #519 verified the five eye drops containers were not dated when opened. Review of the facility policy titled Administration 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-26 · 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, staff interview, resident interview and review of the facility bowel protocol, the facility failed to monitor for bowel movements and failed to administered as needed laxatives as ordered. This affected one (Resident #26) of five residents reviewed for unnecessary medications. The facility census was 73. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 05/04/17. Review of the care plan dated 06/02/17, revealed Resident #26 had a potential for constipation related to increased weakness, decreased mobility, and use of narcotics. Interventions included following bowel management guidelines, monitor abdomen for distention, monitor bowel sounds, provide high fiber foods as needed and record bowel movement size and consistency and report any abnormalities to supervisor. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/27/19, revealed Resident #26 was cognitively intact, occasionally incontinent of bladder and always continent of bowel. Review of the current physician orders for Resident #26 revealed…

    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 · D2019-11-26 · 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 record review, interview and policy review, the failed to ensure restorative range of motion was provided as ordered. This affected one (Resident #49) of two residents reviewed for positioning. The facility identified 24 residents with restorative programs in the last 60 days. The facility census was 73. Findings include: Record review revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, muscle weakness, lack of coordination, chronic obstructive pulmonary disease, depression, anxiety, heart disease, convulsions, cardiac arrhythmia, neuromuscular dysfunction of bladder, migraine gastro-esophageal reflux disease, overactive bladder, left ankle contracture, osteoporosis, insomnia, cataracts and dysphagia. Review of a physician order dated 03/12/19 revealed the resident could have restorative nursing as indicated. Review of a physical therapy Discharge summary dated [DATE] revealed the resident was being discontinued from therapy with recommendations including…

    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 · D2019-11-26 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to monitor the dialysis vascular access for function. This affected one (Resident #26) of five residents that receive dialysis. The facility census was 73. Findings include: Review of the medical record for Resident #26 revealed an admission date of 05/04/17. Diagnoses include end stage renal disease. Review of the care plan dated 06/02/17 revealed Resident #26 was at nutritional/hydration risk related to End Stage Renal Disease (ESRD) on hemodialysis, diabetes mellitus type two, hypertension, congestive heart failure, chronic obstructive pulmonary disease, borderline personality disorder, anemia, depression, chronic ischemic heart disease, sleep apnea, anxiety disorder, limited mobility, fluid restriction, difficulty understanding and following therapeutic diet despite multiple educations. Resident #26 had a potential for infection, blood clot, dehydration and electrolyte imbalance related to hemodialysis. Interventions included checking…

    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
  • No harm found · C2019-11-26 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and staff interview, the facility failed to ensure staffing was accurately posted in a prominent location for residents/visitors to review. This had the potentially to affect all 73 residents residing in the facility at the time of the annual survey. Facility census was 73. Findings include: Observations of the bulletin board near the nursing station on the north west hall on 11/24/19 and 11/26/19 revealed the daily staffing sheet posted was dated 10/17/19. Interview with Licensed Practical Nurse (LPN) #16 on 11/26/19 at 1:57 P.M. confirmed the posted staffing was dated 10/17/19 and was not posted for the current time.

    Nursing and Physician Services Deficiencies · Deficient, Provider has plan 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
WOOD COUNTY AUDITOROrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/01/1971
ORLOWSKI, JEFFIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/09/2025

CMS files one row per role, so the 3 rows in the source record cover these 2 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.

$8.3M
Net patient revenuemost recent cost report
-14.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 19%Medicare 11%Other / private 70%

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

$350per resident / day
operating cost
$10,635per month
≈ monthly operating cost
$307per day
avg. revenue, all payers

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

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 365458. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-09, 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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