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Carriage Inn of Cadiz

308 West Warren Street, Cadiz, OH 43907 · For profit - Limited Liability company · 70 certified beds · (740) 942-8084 Medicare & Medicaid certified

Call the home — (740) 942-8084 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Feb 2024Resident-funds citations (F0567, F0568)1 actual-harm citation$14,991 in federal fines1 Medicare payment denial
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has citations for mishandling residents’ money or property (F0567, F0568)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,991 in federal fines (most recent 2023-11-22)
  • about 17% of its spending goes to commonly-owned related companies

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.

3/5
CMS overall
3 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 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
82424 Cadiz Jewett Rd · (740) 320-4048 · Call to confirm hours
Pharmacy
241 S Main St · (740) 942-2726 · Call to confirm hours
Grocery
264 S Main St · (740) 320-4039 · Call to confirm hours
Park
Deersville,OH,44693 · Typically dawn to dusk
Place of worship
227 W Warren St · (740) 942-2179

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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 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 rating2★
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 increased3.8%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight2.9%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.0%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms8.9%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 injury11.8%3.2%3.3%worse
Long-stay residents whose ability to walk worsened5.3%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication31.4%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine94.4%94.5%95.3%typical
Long-stay residents with pressure ulcers0.5%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control29.1%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.1%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication2.8%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine60.0%75.6%79.4%worse
Short-stay residents rehospitalized after admission37.1%24.9%22.6%worse
Short-stay residents with an outpatient ER visit7.9%12.9%12.0%better
Long-stay hospitalizations per 1,000 resident days2.401.731.67worse
Long-stay outpatient ER visits per 1,000 resident days2.381.801.80worse

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.

41.6% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.6%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
66.7%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.10hours / resident / day
Speech therapy

Met the expected recovery: 66.7% 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 21 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF41.6%CMS range 28.5–58.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 7.2–17.610.7%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 discharge66.7%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 discharge47.6%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 discharge38.1%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 identified100.0%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 settingnot 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 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 stay2.9%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 worsened2.9%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.351.02Oct 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

0.90
RN hours/ resident / day
0.62
LPN hours/ resident / day
2.24
Aide hours/ resident / day
3.75
Total nurse hours/ resident / day
0.44
RN hoursweekends
40.4%
Total nursing turnover
30.8%
RN turnover

How full it usually is: this home is certified for 70 beds and averages 54.5 residents a day — about 78% occupied, or roughly 16 beds typically open. It usually has some room. 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 3.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.24 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 3.12 hrs/resident/day on weekends vs 4.01 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.08 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% 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

6
deficiencies at the latest standard inspection (2025-12-23)
6
at the previous standard inspection (2024-02-08)

Deficiencies are unchanged from the previous inspection. 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.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2023-11-22 · 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 review of the medical record, review of the facility investigation, and interviews with staff, the facility failed to ensure Resident #41 was free from accident hazards. Actual harm occurred on 10/16/23 when Resident #41, who was cognitively impaired, at risk for falls, and dependent on two staff for bed mobility, fell out of bed while State Tested Nursing Assistant (STNA) #112 was providing incontinence care by himself. Resident #41 sustained a fracture to the right hip and hematoma to the back of her head. Resident #41 was transferred to the hospital and received surgical intervention to her right hip. This affected one resident (Resident #41) of three residents reviewed for accident hazards. The facility census was 57. Findings include: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Resident #41's list of diagnoses included diabetes, diabetic polyneuropathy, protein-calorie malnutrition, intertrochanteric fracture of the right femur, atrial fibrillation,…

    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 · D2026-05-28 · tag F0568 — isolated
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    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 funds account review, record review, policy review, and interview, the facility failed to ensure accurate accounting of a resident account. This affected one (Resident #54) of three residents reviewed for Personal Fund Accounts. The facility held funds for 31 current and former residents. The facility census was 53.Findings include:Review of Personal Funds Accounts 05/28/26 with Business Office Manager #100 revealed Former Resident #54's account was closed 05/22/26. The facility was the payee for Resident #54's social security and pension. As of 01/01/26 his personal allowance increased from 50 to 75 dollars. The account had a balance of $100.01 on 01/01/26. Review of the Resident Funds Management Service (RFMS) revealed in January of 2026 the facility allotted a 50-dollar allowance, not the new 75-dollar amount. Resident #54 was hospitalized [DATE] till 02/03/26. In February of 2026 the facility allotted the 75-dollar allowance on 02/03/26 when a social security check for $2791.00 was deposited. 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 · F2025-12-23 · tag F0761 — failed to label and store drugs safely — widespread
    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 observation, record review, and interview, the facility failed to provide safe and secure medication storage, including proper labeling and maintaining temperatures of medication storage refrigerators, of all medications. This had the potential to affect all residents of the facility. The facility census was 51.Findings include:On 12/09/2025 at 9:05 A.M., an observation of the treatment cart in the Kerrozin medication room was performed. The observation revealed Medihoney 1.5-ounce tube which was opened, unlabeled, and undated. The treatment cart observation further revealed a Dermasyn hydrogel wound dressing 3-ounce tube which was opened, unlabeled, and undated. This was confirmed by Registered Nurse (RN) #179 at the time of the observation.On 12/09/2025 at 9:20 A.M., an observation of the medication refrigerator in the medication room of [NAME] Hall revealed the refrigerator held medications and vaccinations for residents. The temperature of this refrigerator was noted to be 60 degrees Fahrenheit (F).…

    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 · F2025-12-23 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility's infection control surveillance logs and interview, the facility failed to adequately monitor for patterns of infection and provide oversight to identify the cause of identified patterns of infection. This had the potential to affect all 51 residents.Findings include:Review of the July 2025 infection surveillance logs revealed six residents had urinary tract infections (UTI), with Resident #7 being treated twice for UTI. The surveillance logs did not contain information regarding what microorganisms were involved. Review of the August 2025 infection surveillance records revealed microorganisms were not monitored. During an interview with Registered Nurse (RN)/Infection Control Preventionist (ICP) #102 on 12/11/25 at 12:13 P.M., RN #102 verified when tracking for patterns of infection, she did not monitor the microorganisms involved. RN #102 stated there had been an increase in UTIs during the summer. There was no documented plan/course of action. RN #102 stated there had been an increase in fluids provided and staff had been educated regarding…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-23 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of infection surveillance records, policy review and interview, the facility failed to ensure antibiotic orders were thoroughly researched to determine if residents met the criteria for infections, failed to ensure when criteria was not met the prescriber was informed, and failed to provide education and reports regarding antibiotic use to prescribers in accordance with policies. This affected three (Residents #7, #21 and #61) of four residents reviewed for antibiotic use and had the potential to affect any other residents for whom antibiotics were ordered.During review of the August 2025 infection surveillance reports, the following were identified:1. Review of Resident #7's medical record revealed diagnoses including secondary Parkinsonism, irritable bowel syndrome, and dementia. A nursing note dated 07/21/25 at 11:00 P.M. indicated new orders were received for a Complete Blood Count (CBC) and a Comprehensive Metabolic Panel (CMP) to be obtained the morning of 07/22/25 and telehealth was…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-23 · 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

    Based on review of medical records, activity calendars, activity logs, facility policy, and interviews with staff and residents, the facility failed to maintain an activity program specific to meet the individualized needs of Resident #40. This affected one resident (Resident #40) of one resident reviewed for the activities program. The facility census was 51.Findings include: Record review of Resident #40 revealed admission to facility on 01/23/25 for diagnosis including encephalopathy (fluid on the brain) adult failure to thrive, depression, moderate protein- calorie malnutrition, surgical after care for large tumor removal to abdomen on 7/8/25, insomnia (inability to sleep), anemia (low blood counts), Alzheimer's disease, dementia (confusion and forgetfulness) with moderate mood disturbances.Review of Resident #40 Minimum Data Set (MDS) quarterly assessment completed on 10/04/25 revealed a Brief Interview for Mental Status score of 4/15 indicating severe cognitive deficit (impaired memory and confusion). Further review of the MDS revealed inattention and disorganized thinking…

    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 · D2025-12-23 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for 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, policy review, staff and resident interviews, the facility failed to provide routine dental services to one (Resident #53) of two residents reviewed for dental services. The facility census was 51.Findings Include:Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including kidney disease, enlarged prostate, lung disease, anemia, high blood pressure, reflux, Alzheimer's Disease, dementia, anxiety and depression.Record review of Resident #53 most recent Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15/15 meaning the resident was cognitively intact with no impairments. The MDS further noted Resident #53 use of wheelchair for mobility and supervision or minimal assistance with transfers and personal care. The MDS also noted no swallowing disorders and that Resident #53 was following a mechanical soft diet.Record review of dental progress notes dated 01/20/25 written by Dentist #310…

    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 · D2025-12-23 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident #26's medication orders and administration record were accurate. This affected one (Resident #26) of six residents reviewed for medication administration. The facility census was 51.Findings include:Review of medical record for resident #26 revealed an admission date of 06/25/21. The resident had diagnoses that included Parkinson's Disease; anxiety disorder, unspecified; unspecified dementia, severe, with agitation; unspecified protein-calorie malnutrition; benign prostatic hyperplasia without lower urinary tract symptoms; essential hypertension; Parkinsonism; schizophrenia; unspecified mood; tremor; other bipolar disorder; specified peripheral vascular diseases; abnormal involuntary movements; vitamin D deficiency; constipation; restlessness; cramp and spasm; encounter for palliative care; anemia; depression; pain in knee; edema; unspecified urinary incontinence; full incontinence of feces; and Alzheimer's disease 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-06-17 · 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, policy review and interview, the facility failed to prepare and serve food in a sanitary manner. This had the potential to affect 54 of 55 residents residing in the facility. The facility identified Resident #55 not receiving nutrition by mouth. The facility census was 55. Findings include: On 06/17/24 between 9:45 A.M. and 10:01 A.M. observations of the kitchen revealed Dietary Director #69 and Dietary [NAME] #73 were observed to have beards and a mustache. Upon entrance to the kitchen, Dietary [NAME] #73 had his beard net below his chin and when the surveyor approached the dishwashing station, Dietary [NAME] #73 raised the beard net to cover his beard; however, his mustache remained uncovered. Dietary [NAME] #73 was washing dishes and removing clean dishes from the low temperature dishwasher at the time of the observation. Dietary Director #69 and Dietary [NAME] #73 were both observed with facial hair approximately one inch in length, uncovered at the time of the observation. On 06/17/24 between 11:56 A.M. and 12:08 P.M., observation of the lunch meal tray…

    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 · Ecited before2024-06-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 observation, record review, incident log review, procedure review and interview, the facility failed to maintain hot water temperatures below 120 degrees Fahrenheit (F). This had the potential to affect 16 residents (#6, #8, #11, #13, #14, #15, #18, #19, #20, #21, #23, #24, #25, #26, #28 and #30) identified by the facility as cognitively impaired and independent with mobility of 34 residents who reside on the 200 and 300 halls. The census was 55. Findings include: Record review revealed Resident #6 and #8 were moderately impaired for daily decision-making and resided on the long-term unit (200 hall). Resident #11, #13, #14, #15, #18, #19, #20, #21, #23, #24, #25, #26, #28 and #30 were severely impaired for daily decision-making and resided on the locked Alzheimer's unit (300 hall). On 06/17/24 at 10:15 A.M., observation of the second floor mechanical room with Maintenance Director (MD) #89 revealed two hot water tanks. One hot water tank was set to 140 degrees Fahrenheit (F) and the second tank did not have a temperature display visible. MD #89 verified the first hot water…

    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 · E2024-02-08 · tag F0567 — failed to protect residents' money held by the home — pattern
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review the facility failed to ensure that witness authorizations were obtained to manage resident funds. This affected five residents (#1, #6, #24, #26, and #56) of five reviewed for personal funds. This had the potential to affect 33 residents whose funds were managed by the facility. The census was 58. Findings include: Review of financial records for Residents #1, #6, #24, #26, and #56 revealed no witness signatures on the Authorization and Agreement to Handle Resident Funds Forms. On 02/06/24 at 2:55 P.M., an interview with the Administrator verified there were no witness signatures on the Resident Fund Management Agreement Forms. On 02/06/24 at 9:40 A.M. an interview with Business Office Manager # 511 verified there were no witness signatures on the Resident Fund Management Agreement Form.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Ecited before2024-02-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 observation and interview, the facility failed to ensure residents disposed of cigarettes in the designated containers and that facility staff supervising residents smoking knew where the fire safety devices were located. This affected four residents (#3, #14, #19, and #20) of four identified by the facility as smokers. The facility census was 58. Findings include: On 02/05/24 at 9:12 A.M., observation of the courtyard, which was the designated resident smoking area, revealed there were 23 cigarette butts scattered throughout the grass, 21 cigarette butts scattered throughout the mulch, and six cigarette butts on the sidewalk. There was no fire extinguisher or fire blanket in the designated smoking area. On 02/05/24 at 9:26 A.M., interview with Licensed Practical Nurse (LPN) #582 verified cigarette butts were in the grass, mulch, and on the sidewalk. LPN #582 confirmed there was no fire extinguisher or fire blanket in the exterior courtyard which was the designated smoking area for residents. On 02/05/24 at 9:37 A.M., interview with Housekeeper #568, who was supervising…

    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 · E2024-02-08 · tag F0725 — failed to have enough nursing staff — pattern
    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

    Based on observation and interview, the facility failed to ensure there was sufficient staff to monitor dining activities on the secure unit. This had the potential to affect all 19 residents who resided on the secure unit. The facility census was 58. Findings include: During observations of the lunch meal delivery and service on 02/05/24 of the secure unit the following was observed: The first meal cart arrived at 12:25 P.M. and staff immediately began serving residents. At 12:43 P.M. all other residents at the main/long table in the dining room were eating or had received their trays with the exception of Resident #12. No staff were present at the table or directly monitoring the residents when Resident #12 reached over and took a bowl of applesauce from Resident #53's tray and started drinking the applesauce from the bowl. When staff did observed Resident #53 with the applesauce they stated they did not know where Resident #53 got it from. At 12:45 P.M., State Tested Nursing Assistant (STNA) #521 sat beside Resident #12 to assist with her meal. One bowl of food was provided 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-08 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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, policy review, and interview, the facility failed to complete a comprehensive assessment to determine if side rails were used as a restraint or an enabler. This affected one (Resident #56) of 24 residents observed for possible restraints. Te census was 58. Findings include: Review of Resident #56's medical record revealed diagnoses including severe dementia with agitation, abnormal posture, mood disorder, generalized muscle weakness and Parkinson's disease. An admission assessment dated [DATE] indicated Resident #56 had a siderail screening tool which indicated Resident #56 was non-ambulatory, had alterations in safety awareness due to cognitive decline, had a history of falls, demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed, had difficulty with balance or poor trunk control, was currently using side rails raised while in bed, and had not expressed a desire to have rails raised while in bed. The assessment indicated siderails…

    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 · D2024-02-08 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to ensure comprehensive assessments were completed accurately related to hospice services and medication use. This affected two (Resident #18 and #35) of 19 residents reviewed for comprehensive assessments. The facility census was 58. Findings include: 1. Review of Resident #18's medical record revealed an admission date of 03/18/17 with diagnoses that included congestive heart failure, dementia and chronic kidney disease. Further review of the medical record including physician's orders revealed on 02/26/23 Resident #18 was admitted to hospice services. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment with a reference date of 11/03/23 indicated Resident #18 was not currently receiving hospice services. A previous quarterly MDS 3.0 assessment with a reference date of 08/03/23 indicated the resident was receiving hospice services. On 02/07/23 at 9:53 A.M. interview with [NAME] President of Clinical Services #581 verified the MDS…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-08 · 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

    Based on medical record review, observations, policy review and staff interview the facility failed to ensure Resident #21 was turned and repositioned as per the care plan and ordered by the physician. The facility also failed to accurately stage pressure ulcer wounds for Resident #44. This affected two (Residents #21 and #44) of two resident reviewed for pressure ulcer wounds. The facility census was 58. Findings include: 1. Review of Resident #21's medical record revealed an admission date of 07/05/22 with admission diagnoses that include a stage four pressure ulcer (full thickness skin loss with exposed bone, tendon or muscle) to the sacral region, Parkinson's disease with dementia and chronic kidney disease. Review of wound assessments revealed a chronic unhealed stage four pressure ulcer wound to the sacrum/coccyx area which was present upon admission. Review of Resident #21's Minimum Data Set (MDS) quarterly assessment with a reference date of 11/08/23 indicated the resident had a severely impaired cognition level and was dependent upon staff assistance for bed mobility.…

    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 · F2023-11-22 · tag F0926 — failed to keep the home smoke-free / fire-safe — widespread
    Have policies on smoking.
    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, interview with staff and review of the facility policy, the facility failed to implement the smoking policy to maintain a safe and clean environment free from discarded cigarette butts at the facility main entrance door. This had the potential to affect all the residents in the facility. The facility census was 57. Findings included: Observation upon entrance to the facility on [DATE] at 8:00 A.M. revealed there were numerous (20 plus) cigarette butts on the left side of the entrance door laying in the mulch beds. On 11/21/23 at 8:30 A.M. an interview with Receptionist #102 verified the cigarette butts in the mulch by the front door, and verified there was no smoking receptacle at the main entrance to extinguish cigarettes properly. On 11/21/23 at 1:20 P.M. an interview with Maintenance Director (MD) #100 revealed there was not supposed to be anyone smoking at the entrance because it was not the designated smoking area. MD #100 explained the housekeepers were supposed to be 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-04-14 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure resident bathrooms were in good repair. This affected four Residents (#12, #28, #31, and #40) of 19 residents reviewed for physical environment . The facility census was 64. Findings included: Observation on 04/11/22 at 2:43 P.M. of the shared restroom for Residents #12, #28, #31, and #40 revealed bath towels stuffed behind the toilet. A moderate amount of water was observed on the bath towel and the toilet was visibly leaking onto the floor. Observation and interview on 04/13/22 at 7:31 A.M. with the Administrator of the shared restroom for Residents #12, #28, #31, and #40 revealed bath towels stuffed behind the toilet. The Administrator confirmed the toilet was leaking and the bath towels were there to collect the water leaking onto the floor. Interview on 04/13/22 at 8:47 A.M. with Housekeeper #400 confirmed she had been placing a clean bath towel behind the toilet daily after she cleaned the bathroom for Residents #12, #28, #31, and #40. She confirmed a month ago the toilet was leaking, and Maintenance #401 fixed…

    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 · D2022-04-14 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to use the correct form to notify Resident #42 and #112 of a change in their skilled nursing benefits. This affected two Residents ( #42 and #112 ) of three Residents reviewed for skilled nursing facility advanced beneficiary notifications (SNFABN). The facility census was 64. Findings included: Record review was conducted of the Skilled Nursing Facility (SNF) Beneficiary Notification Review form provided by the facility to the survey team. The form included Resident #42 and Resident #112 as Residents who were identified by the facility to receive a notice called the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) form CMS-10055. The facility was asked to provide a completed copy, as provided to Resident #42 and #112, of the SNFABN CMS-10055 forms to the survey team as evidence the Residents were indeed issued the appropriate notifications. Record review was conducted of Advanced Beneficiary Notice (ABN) CMS-R-131 for Resident #42 and #112, as the facility had issued CMS-R-131 to them instead of the SNFABN form…

    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 · D2022-04-14 · tag F0646 — isolated
    Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
    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 interview and record review the facility failed to accurately complete the Preadmission Screening and Resident Review Result notice (PASRR) for a significant change in status. This affected two (Residents #23 and #52) of two residents reviewed for PASRR. The facility census was 64. Findings included: 1. Review of the medical record for Resident #23 revealed an admission date of 08/22/14. Diagnoses included type two diabetes mellitus, chronic kidney disease stage three, and schizophrenia. Review of physician's order dated 05/18/21 revealed Resident #23 was ordered pimavanserin tartrate (antipsychotic medication) for schizophrenia. Review of the significant change of status PASRR dated 01/19/22 for Resident #23 was marked he had no mental illness diagnoses. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #23 revealed he had a mental illness diagnoses of schizophrenia. Interview on 04/12/22 at 4:00 P.M. with SS #403 confirmed she did answer that question wrong; 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff interview, the facility failed to ensure a resident, who required an extensive assist of one from staff for personal care, received the assistance needed to keep his fingernails trimmed. This affected one (Resident #57) of four residents reviewed for activities of daily living (ADL's). The facility census was 64. Findings included: A review of Resident #57's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included need for assistance with personal care, major depressive disorder, congestive heart failure, Alzheimer's disease, muscle weakness, adult-onset diabetes mellitus, and dementia with behavioral disturbances. A review of Resident #57's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was usually able to make himself understood and was usually able to understand others. His cognition was severely impaired and he was not known to have displayed any behaviors or reject care. He required an extensive…

    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 · D2022-04-14 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident interview, medical record review and staff interview the facility failed to provide joint movement services or splint use for residents identified with limited range of motion. This affected one (Resident #35) of one residents reviewed for range of motion services. The facility census was 64. Findings included: Observation of Resident #35 on 04/11/22 at 12:49 P.M. revealed the right wrist contracted in a flexed position. Additional observation on 04/13/22 at 8:34 A.M. revealed Resident #35 was able to independently complete passive range of motion (manually move an affected joint using something besides the affected extremity ). At no time during the annual survey was any type of splint device or range of motion services observed in place for Resident #35. Review of Resident #35's medical record revealed an admission date of 03/09/18 with admission diagnosis that included cerebrovascular accident with hemiplegia (stroke with weakness to one side of the body). Review of the Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 03/04/22…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-14 · 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, staff interview and policy review, the facility failed to ensure a resident's fall prevention interventions were implemented as per their plan of care. This affected one (Resident #59) of two residents reviewed for falls. The facility census was 64. Findings included: A review of Resident #59's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included muscle weakness, need for assistance with personal care, abnormalities of gait and mobility, dementia with behavioral disturbances and a fall resulting in a displaced fracture of distal phalanx of right lesser toes (3rd and 4th metatarsals). A review of Resident #59's active physician's orders revealed she had an order in place for Dycem to be used in the wheelchair every shift for a fall. The order originated on 03/22/22. A review of Resident #59's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately…

    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 · D2022-04-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #54 received therapeutic dietary interventions to prevent weight loss. This affected one resident (#54) of three residents reviewed for nutrition and weight loss. The facility census was 64. Findings included: Review of Resident #54's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, dementia and chronic pain. Review of Resident #54's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem and the resident had a weight loss of 5% (percent) or more in the last month or 10% or more in the last six months. Review of Resident #54's physician orders revealed an order dated 05/13/21 for half a cup (4 ounces) of fortified mashed potatoes at lunch and dinner. Review of Resident #54's care plan revealed an intervention dated 05/22/19 to provide diet and fluids as ordered an an intervention dated 09/22/20 to provide…

    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

“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

$14,991 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $14,991 — penalty dated 2023-11-22
  • Medicare payment denial — starting 2024-06-13 for 6 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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.

$6.3M
Net patient revenuemost recent cost report
-18.1%
Operating marginrevenue minus expenses
$1.3M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 73%Medicare 6%Other / private 22%

About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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. 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

$338per resident / day
operating cost
$10,264per month
≈ monthly operating cost
$286per 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 365342. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-23, 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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