Burbank Parke Care Center
14976 Burbank Road, Burbank, OH 44214 · For profit - Corporation · 81 certified beds · (330) 624-1030 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 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 improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.4% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 6.1% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.1% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 66.8% | 30.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.6% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 5.4% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 33.0% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.6% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.2% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 12.0% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.1% | 8.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.4% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 79.4% | 75.6% | 79.4% | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
49.7% 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 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 49.7%CMS range 35.5–68.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 6.8–15.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not 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 discharge | not 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 discharge | not 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 identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not 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 worsened | not 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 hospitalization | not 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 SNFs | 0.84 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 81 beds and averages 76.4 residents a day — about 94% occupied, or roughly 5 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 3.478 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.80 hrs/resident/day on weekends vs 3.75 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.57 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 29% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
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.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · Dcited before2024-09-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure interventions to maintain skin integrity were implemented per the resident's care plan. This affected one (Resident #50) of five sampled residents. The facility census was 71. Findings include: Review of Resident #50's medical record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease, hypoxemia, severe dementia, delusional disorder, anxiety, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 was rarely understood, was receiving hospice services, and was dependent for activities of daily living. Review of Resident #50's physician orders for September 2024 revealed an order dated 10/17/23 for soft elbow pads implemented daily for skin protection. Review of Resident #50's care plan revealed Resident #50 had actual or potential for alteration in skin integrity related to diagnoses and resistance to care. An intervention…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-26 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure enhanced barrier precautions (EBP) were implemented as required for Resident #65. This had the potential to affect ten residents (#55, #56, #57, #58, #59, #60, #61, #62, #63, and #64) that resided on the same hall as Resident #65. Findings include: Review of Resident #65's medical record revealed the resident was admitted on [DATE] with diagnoses that included but not limited to Alzheimer's disease, angina pectoris, major depressive disorder, and atherosclerotic heart disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 was severely cognitively impaired and required maximal assistance with activities of daily living. Review of the physician's orders for July 2024 revealed Resident #65 did not have a urinary catheter. Review of the physician orders dated 07/22/24 revealed that Resident #65 was ordered one gram of ertapenem sodium (antibiotic) for extended spectrum beta-lactamase…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure staff followed appropriate hand hygiene and glove use when completing pressure ulcer treatments. This affected one of three residents (Resident #24) for pressure ulcer dressing changes. The census was 72. Findings Included: Review of the open medical record for Resident #24 revealed an admission date 03/13/23. Diagnoses included diabetes type 2 and Stage 4 pressure ulcer (Full-thickness skin and tissue loss). Review of the physician orders for July 2024 revealed a treatment to cleanse sacrum with normal saline, apply collagen sheet to wound bed, Skin prep peri wound and cover with border gauze dressing. Observation of Resident #24's dressing change on 07/26/24 at 9:31 A.M. with Licensed Practical Nurse (LPN) #303 and State Tested Nurses Assistant (STNA) #366 revealed LPN #303 and STNA #366 both used hand sanitizer as they entered the room. LPN #303 setup the supplies needed for the dressing change. LPN #303 removed the old dressing and discarded the dressing and the gloves she was wearing. LPN #303…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, resident interview, staff interview and review of the facility policy, the facility failed to ensure residents were transferred in a safe manner and in accordance with the plan of care in order to prevent injury. This affected one (Resident #10) of three residents reviewed for assistance with activities of living (ADLs). The facility census was 68. Findings include: Review of the medical record for Resident #10 revealed an admission date of 06/26/21 with diagnoses included hemiplegia, cerebral infarction, aphasia, diabetes mellitus, osteoarthritis, intervertebral disc degeneration, major depressive disorder, and aftercare joint replacement surgery. Review of the physician order for Resident #10 dated 10/20/23 revealed the resident was a stand-pivot transfer with assistance of one staff using hemi-walker for transferring and could use a mechanical lift as needed every shift for transfers. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #10 dated 01/18/24 revealed the resident had moderate cognitive impairment,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-12-29 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure cold, perishable food (milk) was maintained a proper temperatures. This had the potential to affect all 66 residents in the facility. Findings include: Interviews on 12/27/23 between 9:28 A.M. and 11:01 A.M. with Residents #34, #42, and #66 complained of the food temperatures of the meals when they received them in their rooms. Observation on 12/28/23 at 11:44 A.M. of tray line services for halls trays revealed three silver, open meal carts set up with meal trays that had pre-poured beverages including milk. Observation on 12/28/23 at 12:38 P.M. of the last tray served for the hall meal trays. At this time the test tray was preformed and revealed the beef stew and green beans very warm to hot and tasted very good. The pre -poured glass of milk tempted at 55 degrees Fahrenheit. Interview at this time with Dietary Manager (DM) #836 stated the milk should be colder. Reviewed policy Food Preparation and Service revised November 2022 revealed food and nutrition services employees prepare, distribute, and serve food in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-12-29 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews, the facility failed to maintain a clean and sanitary nursing unit refrigerator and failed to ensure milk was stored safely to maintain proper temperature during meal service. This had the potential to affect all 66 residents. Findings include: 1. Observation on 12/28/23 between 8:16 A.M. and 8:28 A.M. of the nursing unit refrigerator on the 700 and 800 hall revealed in the freezer a large brownish frozen food splatter and in the refrigerator various food splatter and a black residue on the inside back wall. Interview at this time with Dietary Manager (DM) #836 verified the observations. 2. Observation on 12/28/23 at 8:38 A.M. of Registered Dietitian (RD) #805 passing breakfast trays on the 500 hall. Observed on the beverage care a gallon of opened milk sitting out on the cart. Interview at this time with RD #805 verified the observation and stated they take the milk out of the refrigerator on unit and it was usually out for about hour while meal trays were being passed. RD #805 stated then the milk was put right back into the refrigerator after…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-29 · tag F0641 — patternEnsure 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 observation, record review and interview, the facility failed to ensure comprehensive assessments were complete and accurate. This finding affected four (Residents #15, #50, #51, and #64) of 24 residents reviewed for comprehensive assessments. Findings include: 1. Review of Resident #15's medical record revealed the resident was admitted on [DATE] with anxiety disorder, depression and chronic obstructive pulmonary disease. Review of Resident #15's physician orders revealed an order dated 08/30/23 to admit to hospice services with a diagnosis of cerebral atherosclerosis. Review of Resident #15's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] under Section O - Special Treatments, Procedures, and Programs did not reflect the resident was receiving hospice services. Interview on 12/27/23 at 4:44 P.M. with Registered Nurse (RN) MDS #801 confirmed Resident #15's comprehensive assessment dated [DATE] did not reflect the resident's hospice services. 2. Review of Resident #15'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.
- Potential for harm · E2023-12-29 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure accurate serving sizes were served for the pureed meal. This affected two residents (#3 and #39) but had the potential to affect all 10 residents (#1, #3, #9, #12, #19, #23, #36, #39, #47, and #55) residents who received pureed diet. The facility census was 66. Finding included: Review of menu and menu spreadsheet dated 12/28/23 revealed for the pureed meal was #6 scoop serving for the pureed beef stew, #16 scoop serving for the pureed green beans, and #30 scoop serving for the pureed biscuit. Observation on 12/28/23 at 11:44 A.M. of tray line service revealed grey handled scoops placed in each of the pureed beef stew, pureed green beans, and pureed biscuits. Observed at 11:57 A.M. of [NAME] #885 prepare a pureed meal using the gray handled scoop for each pureed item, one serving each, and placed on the tray on the second meal cart for hall trays. Observed at 12:04 P.M. [NAME] #885 prepare another pureed meal using the gray handled scoop for each pureed item, one serving each, and placed on tray on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #15's sacral pressure ulcer wound dressing was in place. This finding affected one (Resident #15) of two residents reviewed for pressure ulcers. Findings include: Review of Resident #15's medical record revealed the resident was admitted on [DATE] with diagnoses including cerebral atherosclerosis, depression and anxiety. Review of Resident #15's physician orders revealed an order dated 11/17/23 to cleanse the area to the coccyx with normal saline, apply a collagen sheet to the wound bed, apply calcium alginate, apply skin prep to the peri wound and cover with a silicone super absorbent border foam dressing three times a week and as needed every Monday, Wednesday and Friday for wound care. Review of Resident #15's wound progress note dated 12/13/23 revealed the resident had a stage four full thickness coccyx pressure wound which measured 2.6 cm (centimeters) by 0.9 cm by 1.1 cm with 10% slough and 90% granulation tissue.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #51's fall interventions were implemented according to the physician orders and care plans. This finding affected one (Resident #51) of five residents reviewed for accidents and hazards. Findings include: Review of Resident #51's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, major depressive disorder and unspecified dementia. Review of Resident #51's physician orders revealed an order dated 10/29/22 to keep the bed in the lowest height when in bed and an order dated 12/04/23 for a perimeter mattress to the bed for safety. Review of Resident #51's Fall Investigation form dated 11/21/23 revealed the State Tested Nursing Assistant (STNA) found the resident on the floor by the bed. The resident could not state what he was doing. The fall interventions listed included a non-skid floor mat at the bedside and a low bed.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · D2023-12-29 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management 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 and interview, the facility failed ensure Resident #51's narcotic pain medications were administered as ordered and failed to adequately monitor and assess Resident #51's pain levels prior to and following administration of the narcotic pain medications. This finding affected one (Resident #51) of two residents reviewed for pain management. Findings include: Review of Resident #51's medical record revealed the resident wad initially admitted on 1214/21 and readmitted on [DATE] with diagnoses including major depressive disorder, pulmonary hypertension and hospice services. Review of Resident #51's Pain Level Summary form from 12/01/23 to 12/28/23 revealed the resident's pain was monitored on 12/16/23 at 12:33 A.M. with a pain level of ten (one being the least pain and ten the worst pain); on 12/16/23 at 7:51 A.M. with a pain level of five and on 12/28/23 at 12:34 P.M. with a pain level of eight. No other documentation was available related to assessment and monitoring of the resident's pain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-29 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement non-pharmacological interventions prior to administering Resident #3 and Resident #53's anti-anxiety medication. This finding affected two (Residents #3 and #53) of five residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #3's medical record revealed the resident was admitted on [DATE] with diagnoses including vascular dementia, neuromuscular dysfunction of the bladder and low back pain. Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #3's physician orders revealed an order dated 05/06/23 for Lorazepam (anti-anxiety medication) 0.5 mg give one tablet by mouth every four hours as needed for agitation and anxiety. Review of Resident #3's medication administration records (MARS) from 12/01/23 to 12/28/23 revealed the resident received the as needed anti-anxiety medication on 12/1/23 at 1:05 P.M., 12/01/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-29 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5% (percent). Twenty-five medications were observed with two errors for a medication error rate of 8%. This finding affected one (Resident #53) of four residents observed for medication administration. Findings include: Review of Resident #53's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, dementia and primary generalized osteoarthritis. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #53's physician orders revealed an order dated an order dated 08/04/22 to give one scoop of fiber powder by mouth one time a day for diarrhea; an order dated 08/23/22 for Brimonidine Tartrate solution 0.2% (percent) instill one drop in the left eye two times a day related to unspecified glaucoma and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-29 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and policy review, the facility failed to ensure basic infection control practices were maintained related to catheter bag placement for Resident #5. This affected one resident (Resident #5) of one resident reviewed for catheter care. The facility census was 67. Findings Include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), dementia and neuromuscular dysfunction of the bladder. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was cognitively intact, required extensive assistance of one staff person for completing her activities of daily living and the use of indwelling foley catheter to empty her bladder. Observation of Resident #5 on 12/27/23 at 10:29 A.M. revealed Resident #5 was up and sitting in her recliner. Resident #5's foley catheter bag was uncovered, touching the floor and hanging on a trash can next to the recliner with trash…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-01-20 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, review of a test tray, review of resident council minutes, diet list review and recipe review, the facility failed to ensure foods were served at safe and palatable temperatures and failed to ensure pureed items were prepared appropriately. This affected 66 of 67 residents residing in the facility as Resident #43 received nothing by mouth (NPO). Findings include: 1. Interviews on 01/10/22 from 10:36 A.M. to 5:08 P.M. and on 01/11/22 at 10:45 A.M. with Residents #10, #16, #27, #32, #34, #46, #51 and #68 indicated concerns regarding food being served cold and food not being palatable. Observation on 01/12/22 starting at 11:30 A.M. revealed [NAME] #317 tested temperatures of the meal to be served using the facility's self-calibrating thermometer. Temperatures were as follows: carrots 160 degrees Fahrenheit (F); ham, 191 degrees F; oven roasted potatoes, 165 degrees F; alternate meal of stuffed pepper casserole, 196 degrees F; fruited jello, 38 degrees F. Lunch service started at 11:37 A.M. Five meal carts were observed to be used for meal service across…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-01-20 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, observation, and review of facility policy, the facility failed to ensure staff screened for COVID-19 signs and symptoms prior to working, failed to ensure proper use and disposal of personal protective equipment (PPE) was in place. This had the potential to affect all 67 residents in the facility. Findings included: 1. Review of the facility COVID-19 testing revealed State Tested Nursing Assistant (STNA) #349 tested positive on 01/11/21, STNA #390 tested positive on 01/10/22, and Therapy assistant #396 tested positive on 01/10/22. Review of the screening logs and time punches for three staff, STNA #349, STNA #390 and Therapy Assistant # 397 revealed the following: STNA #349 worked on 01/01/22 from 6:17 A.M. through 3:12 P.M., 01/02/22 from 6:19 A.M. through 7:06 P.M., 01/03/22 from 6:03 A.M. through 3:01 P.M., 01/05/22 from 2:18 A.M. through 3:33 P.M., 01/06/22 6:13 A.M. through 3:23 P.M., 01/07/22 from 6:06 A.M. through 3:10 P.M., 01/08/22 from 2:21 A.M. through 3:00…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure respiratory equipment was maintained in a sanitary manner. This affected one resident (Resident #65) of two residents reviewed for respiratory care. Findings include: Review of Resident #65's medical record revealed an original admission date of 06/18/21 and diagnoses including chronic obstructive pulmonary disease (COPD), moderate protein-calorie malnutrition, depression, anxiety disorder, anemia, chronic respiratory failure and hypertension (high blood pressure). Review of census data revealed Resident #65 was on hospice care as of 08/20/21 and showed admissions to the facility from 06/18/21 to 07/11/21, from 07/26/21 to 08/14/21, from 08/20/21 to 12/04/21 and from 12/13/21 to present. Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact and required supervision for bed mobility, eating and ambulation off of the unit. Resident #65 did not have upper or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-20 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident #44's assistive device for drinking was in place as ordered. This affected one resident (Resident #44) out of four residents reviewed for adaptive equipment. Findings include: Review of the medical record for Resident #44 revealed an admission date of 05/31/19. Diagnoses included Alzheimer's disease, dysphagia oropharyngeal, insomnia, delusional disorder, anxiety disorder, psychotic disorder, and major depressive disorder. Review of Resident #44's care plan, dated 06/03/19, revealed episodes of nutritional problems, abdominal pain, indigestion, nausea/vomiting, diarrhea, constipation, and dysphagia related to gastroesophageal reflux disease and irritable bowel syndrome. Interventions include diet per registered dietician (RDLD) recommendations and physician orders. Altered nutritional status was evidenced by inadequate intake, underweight Body Mass Index less than 19, difficulty chewing/swallowing, required feeding…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-02-28 · tag F0641 — isolatedEnsure 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 record review and interview, the facility failed to ensure Residents #20, #49 and #51's comprehensive assessments were complete and accurate. This finding affected three residents (Residents #20, #49 and #51) of twenty-six resident records reviewed for comprehensive assessments. The facility census was 70. Findings include: 1. Review of Resident #20's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, Alzheimer's disease with late onset and major depressive disorder. Review of Resident #20's Minimum Data Set (MDS) 3.0 assessment, dated 12/12/18, revealed the resident exhibited severe cognitive impairment and did not have moisture associated skin damage (MASD). MASD is described as skin damage from incontinence-associated dermatitis, perspiration or drainage. Review of Resident #20's skin assessment, dated 12/12/18, indicated the resident had MASD to the resident's bilateral buttocks and the first date…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-02-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two Residents (#20 and #26) had measurable goals for one to one (1:1) activities, and failed to have documentation of what the 1:1 activities were to consist of. Three residents (#20, #26, and #35) were reviewed for activities. The facility census was 70. Findings included: Review of the medical record revealed Resident #26 was admitted on [DATE] with diagnoses including muscle weakness, trigeminal neuralgia, osteoarthritis, abnormal electrocardiogram (EKG), hypothyroidism, hyperlipidemia, dementia, major depression, anxiety, hypertension, atherosclerosis heart disease, cardiac arrhythmia, cerebrovascular disease, constipation, dizziness, and malaise. The comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 12/23/18, indicated the residents cognitive assessment could not be assessed. Review of the activity note, dated 12/17/2018, indicated the resident preferred to stay in her room rather than participate in activities. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-02-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #20's fingernails were clean and sanitary. This finding affected one (Resident #20) of one resident reviewed for activities of daily living. The facility census was 70. Findings include: Observation on 02/25/19 at 9:40 A.M. revealed Resident #20 was sitting in a specialized chair by the nurses station. The resident's thumb, pointer and middle finger of the left hand had brown matter caked under her fingernails. Observation on 02/26/19 at 12:52 P.M. with Registered Nurse (RN) #806 revealed Resident #20 had brown matter caked under her left thumb, pointer and middle fingers. RN #806 confirmed nail care should have been completed with morning care. Review of Resident #20's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, Alzheimer's disease with late onset and depressive disorder. Review of Resident #20's Minimum Data Set (MDS) 3.0…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-02-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #51's fall interventions were in place. This finding affected one (Resident #51) of five residents reviewed for accidents. The facility census was 70. Findings include: Observation on 02/27/19 at 3:00 P.M. with Licensed Practical Nurse (LPN) #805 revealed Resident #51 was in bed sleeping on his right side, and a fall mat was not located next to the resident's bed as ordered by the physician. Review of Resident #51's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hospice services, repeated falls and dementia. Review of Resident #51's Minimum Data Set (MDS) 3.0 assessment, dated 01/21/19, revealed the resident exhibited severe cognitive impairment. Review of Resident #51's medical record revealed the resident had recent falls, including falls on 11/28/18, 12/18/18, 01/02/19, 01/06/19, and 01/17/19. Review of Resident #51's fall care plan confirmed an fall intervention,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to JAG HEALTHCARE — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.3 | +0.7 vs chain |
| Health inspection | 3 of 5 | 2.9 | +0.1 vs chain |
| Staffing | 2 of 5 | 2.4 | -0.4 vs chain |
| Quality measures | 5 of 5 | 4.6 | +0.4 vs chain |
The other 8 homes this chain runs (chain average 3.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BURBANK PARK RE, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2017 |
| GRIFFITHS, JAMES | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2013 |
| JAG HEALTHCARE INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2013 |
| FISER, LAUREN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| KHANDELWAL, SHOBHA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/16/2010 |
CMS files one row per role, so the 12 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $974K paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366392. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-12-29, 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.