Calcutta Health Care Center
48444 Bell School Road, Calcutta, OH 43920 · For profit - Corporation · 97 certified beds · (330) 385-7100 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0602), cited Nov 2023
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $25,495 in federal fines (most recent 2026-04-01)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- about 22% of its spending goes to commonly-owned related companies
- 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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 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, and staffing on its payroll (PBJ) submissions — 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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 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.
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 | 8.4% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 3.1% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.7% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 8.8% | 30.1% | 6.5% | better 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 | 5.5% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.8% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 32.4% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.3% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.6% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.8% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.8% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.0% | 12.9% | 12.0% | 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.
55.4% 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 166 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.6% 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 93 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 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% 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 | 55.4%CMS range 47.0–62.9 | 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 | 14.8%CMS range 11.6–19.7 | 10.7% | Oct 2022–Sep 2024 | worse than 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 | 65.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 63.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 69.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 | 0.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.6%CMS range 5.9–14.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.09 | 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 97 beds and averages 90.9 residents a day — about 94% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.91 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 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 3.06 hrs/resident/day on weekends vs 4.26 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 1.07 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% 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
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.
31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-04-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, review of the ambulance run report, review of hospital records, review of death certificate, interviews with staff, physicians and resident power of attorney (POA), and review of facility policies, the facility failed to provide adequate monitoring and timely identification of an acute change in condition to prevent a delay in treatment for Resident #98. This resulted in Immediate Jeopardy and Actual Harm (subsequent death) beginning on 11/23/25 at approximately 1:40 A.M. when Resident #98, who had a known history of oral phase dysphagia, pneumonitis due to inhalation of food and vomit, use of antiplatelet therapy and was care planned for aspiration risk, and bleeding risk related to antiplatelet therapy, began to have brown emesis which continued throughout the midnight shift without proper assessment by the assigned nurse who proceeded to administer medications (on 11/23/25 RISE) via oral route without evidence of checking the oral cavity, completing a physical…
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.
- Actual harm · G2019-07-25 · 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
Based on observation, medical record review, review of the facility's pain management protocol and staff interview, the facility failed to conduct a comprehensive pain assessment and provide interventions to prevent and/or alleviate pain for one resident (Resident #358). Actual Harm occurred for Resident #358 on 07/24/19 at 10:22 A.M. when Resident #358 was grimacing, fidgeting, twisting his trunk around, yelling repeatedly this is terrible, and pulling on the hemi-tray on his wheelchair. This affected one (Resident #358) of one residents reviewed for pain. All 113 residents were screened for signs of unrelieved pain. Findings include: Review of Resident #358's medical record revealed an admission date of 07/13/19. Diagnoses included a malignant neoplasm of the brain, memory deficit following a stroke, low back pain, and urinary tract infection. Skin and wound evaluations dated 07/13/19 indicated Resident #358 had unstageable pressure injuries (ulcers with obscured full-thickness skin and tissue loss) on the coccyx, left buttock and right buttock. The admission nursing assessment…
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 · D2026-04-01 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of facility policy the facility failed to ensure the physician was thoroughly informed and timely notified of a change of condition for Resident #98 in order to identify and authorize proper treatment. This affected one resident (#98) of six residents reviewed for change of condition. The facility census was 97. Findings include: Review of the closed medical record for Resident #98 revealed an admission date of 11/17/25 with diagnoses including but not limited to weakness, difficulty walking, oral phase dysphagia, muscle wasting, protein-calorie malnutrition, pneumonitis due to inhalation of food and vomit, asthma, cardiac implant and viral meningitis. Resident #98 was emergency transferred from the facility to the hospital emergency room on [DATE] and expired in the hospital on [DATE].Review of physician orders dated 11/17/25 revealed Resident #98 had a Do Not Resuscitate Comfort Care Arrest (DNRCC-A) order indicating standard care and life extending measures…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-05 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the medical record, interview with staff, and review of the facility policy, the facility failed to ensure physician orders were followed to adequately monitor and obtain a blood pressure and heart rate prior to the administration of medication for Resident #24. This affected one resident (Resident #24) of three residents reviewed for medication administration. Findings included: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included hemiplegia of right side following a cerebral infarction, aphasia, convulsions, atherosclerotic heart disease, hypertensive heart disease, chronic kidney disease, peripheral vascular disease, congestive heart failure, major depressive disorder, benign prostatic hyperplasia, generalized edema, gout, and insomnia. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #24 had moderately impaired cognition and he was nonverbal. Review of the March 2025 physician orders…
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 · F2024-06-06 · tag F0725 — failed to have enough nursing staff — widespreadProvide 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
THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the Payroll-Based Journal Staffing Data Report (PBJ), review of staffing schedules, staff interviews, and review of a Facility Assessment, the facility failed to ensure adequate staffing ratios were maintained for the 4th Quarter of 2023. This had the potential to affect all 93 residents. Findings Include: 1. Review of the PBJ report revealed excessively low weekend staffing for the 4th quarter of 2023 was an area of concern. 2. Review of the staffing schedules for the nurses and State Tested Nurse Aides (STNA) for October, November, and December of 2023 revealed the facility did not have consistent and adequate weekend staffing. Completion of the staffing tool revealed inadequate staffing levels for the following dates: 10/07/23 was at 2.10, 10/08/23 was at 2.42, 12/02/23 was at 2.37, 12/09/23 was at 2.45, and 12/10/23 was at 2.33. 3. Interview on 06/04/24 at 2:16 P.M. with the Director of Nursing (DON) confirmed he was aware that staffing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-06-06 · 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, interview, and facility policy review, the facility failed to ensure food was prepared, served, and stored under sanitary conditions. This had the potential to affect 89 residents who received food from the kitchen. The facility identified four residents (#6, #32, #35, and #395) as receiving nothing by mouth. The facility census was 93. Findings include: 1. Observation during the kitchen tour on 06/03/24 from 8:10 A.M. to 8:45 A.M. with Dietary Supervisor (DS) #496 revealed the following concerns: -The floor of the walk-in freezer had a build of dirt and debris under the shelving units and frozen peas were scattered over the floor. -In the walk-in freezer, there was one gallon size storage bag with seven biscuits dated 05/30/24 unsealed and open to air. -In the walk-in cooler, there were two five-pound containers of sour cream with a best buy date of 06/01/24. -In the dry storage area, there was one ten-pound bag of dried angel hair pasta one fourth full open to air and not dated, and there was one two-pound bag of brown sugar opened and resealed with no 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 · Ecited before2024-06-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility menu and spread sheets, the facility failed to ensure the menu was followed and correct portion sizes were served for lunch on 06/04/24 for residents on a mechanical soft diet. This affected 13 residents (#3, #5, #14, #15, #24, #28, #52, #58, #68, #75, #84, #90, and #346) out of the 14 residents who the facility identified as being on a mechanical soft diet. This had the potential to affect 89 residents who received meals from the kitchen. The facility identified four residents (#6, #32, #35, and #395) as receiving nothing by mouth. The facility census was 93. Findings include: Review of the resident choice meal for lunch on 06/04/24 revealed pizza pasta casserole, Prince [NAME] vegetable medley, and lemon strawberry fluff dessert would be served. Review of spread sheets for the lunch meal on 06/04/24 revealed both the regular and the mechanical soft consistency diets would receive eight ounces of the pizza pasta casserole, 4 ounces of the Prince [NAME]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-06 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility recipe, the facility failed to ensure food was served at an appetizing temperature and acceptable palatability. This had the potential to affect 89 residents who received meals in the facility. The facility identified four residents (#6, #32, #35, and #395) as receiving nothing by mouth. The facility census was 93. Findings include: Observation on 06/04/24 from 11:04 A.M. to 11:10 A.M. of Dietary [NAME] #480 taking the temperature of the food items on tray line revealed the pizza pasta casserole was 185 degrees Fahrenheit (F), Prince [NAME] Vegetables was 174 degrees F, the milk was 38 degrees F, and the lemon strawberry fluff dessert was 35 degrees F. Tray service for the dining rooms and hall trays began at 11:15 A.M. As the second to the last cart for 100 hall was finished being loaded, the surveyor requested at 12:20 P.M. a test tray be added at the end of the last cart for 200 hall. The test tray was plated at 12:31 P.M. and placed on the 200 hall cart. The cart…
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 before2024-06-06 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident and staff interviews, record review, and facility policy, the facility failed to ensure Resident #251's right to attend an activity program was honored. This affected one resident (#251) out of 28 residents reviewed for choices. The facility census was 93. Findings include: Review of Resident #251's medical record revealed an admission date of 05/31/24. Diagnoses included nondisplaced intertrochanteric fracture of left femur, difficulty in walking, unspecified fall, acute kidney failure with tubular necrosis (kidney tubules are damaged or destroyed), and type two diabetes without complications, muscle wasting and atrophy (reduced muscle mass) , essential hypertension (high blood pressure), and weakness. Review of Inspira- Activities Initial Review, dated 06/03/24, revealed Resident #251's past activity interests included reading, crocheting, crossword puzzles, solitaire, and bingo, and the resident wished to participate in activities while in the facility. Review of Resident #251's care plan dated 06/03/24 revealed the resident was a new admit to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, review of protocols, and interview, the facility failed to ensure interventions/orders were implemented to protect resident's skin from injuries. This affected one (Resident #50) of three residents reviewed for non-pressure skin related impairments. The facility census was 93. Findings include: Review of Resident #50's medical record revealed diagnoses including Alzheimer's disease, stage three chronic kidney disease, and protein-calorie malnutrition. Review of a care plan initiated 11/24/21 indicated Resident #50 had a potential for alteration in skin integrity related to decreased physical mobility. Skin was fragile, bruised and tore easily. Interventions included applying geri-sleeves to both upper extremities to be on at all times except for bathing and hygiene. Review of a skin and wound evaluation dated 05/31/24 revealed Resident #50 had a skin tear on the right outer forearm which was acquired in the facility on 05/24/24. The skin tear measured 6.1 centimeters (cm) in length and 4.3 cm in width. Review of a physician order dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assist Resident #1 with applying her splint for her right-hand contracture. This affected one out ( Resident #1) of two residents reviewed for limited range of motion. The facility census was 93. Findings include: Review of Resident #1's medical record revealed an admission date of 02/23/05. Diagnoses included Alzheimer's Disease, spastic hemiplegic cerebral palsy, and neuropathy. Review of Resident #1's quarterly minimum data set (MDS) assessment date 03/08/24 revealed the resident is cognitively intact and had an impairment on one side of her upper extremity (shoulder, elbow, wrist, hand). Review of Resident #1's GG Functional Abilities and Goals evaluation dated 03/08/24 revealed the resident is dependent for upper body dressing and lower body dressing. Review of Resident #1's June 2024 physician orders revealed an order dated 05/23/19 to monitor skin integrity of right hand every shift related to splint use. Review of Resident #1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-06 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to ensure the bag of tube feeding product was properly documented with the time and date of when hung as required. This affected one resident (#35) out of one resident reviewed for tube feeding but had the potential to affect four additional residents (#6, #30, #32, and #148) who received continuous interal (a way of delivering nutrition directly to the stomach through a tube) feedings. The facility census was 93. Findings include: Review of medical record for Resident #35 revealed an admission date of 05/06/21. Diagnoses included cerebral palsy, severe intellectual disabilities, adult failure to thrive, unspecified protein-calorie malnutrition, pharyngeal phase dysphagia (difficulty swallowing), and abnormal posture. Further review of the medical record revealed a physician order dated 05/06/21 for NPO (nothing by mouth) diet and an order dated 04/19/24 for enteral feeding of Nutren 2.0 at 40 milliliter(ml)/hour continuous with 55 ml water flush continuous. Review of 05/24/21 care plan…
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.
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- Potential for harm · D2024-06-06 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and facility policy review, the facility failed to ensure communication between the facility and the dialysis center was being received after every dialysis treatment as required and weights were being completed as ordered. This affected one resident (#248) out of one resident reviewed for dialysis. The facility identified Resident #248 as the only resident receiving dialysis. The facility census was 93. Findings include: Review of medical record for Resident #248 revealed an admission date of 05/08/24. Diagnoses included type two diabetes mellitus, kidney transplant failure, end stage renal disease, hypertensive chronic kidney disease with stage five kidney disease, anemia in chronic kidney disease, hyperkalemia (high potassium levels in the blood), hypocalcemia (low calcium levels in the blood), and dependence on renal dialysis. Review of 05/15/24 admission/Medicare five-day Minimum Data Set (MDS) assessment revealed Resident #248 was cognitively intact, required substantial/maximum assistance from staff for transfer, and received dialysis.…
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 · E2023-11-17 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
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, self-reported incident (SRI) review, and record review, the facility failed to ensure residents were free of misappropriation and the resident and/or family was notified of their funds being misappropriated. This affected Residents #3, #5, #6, #18, #21, 37, #41, #42, #43, #45, #51, #59, #60, #61, #63, #66, #101, #102 and #103, with the potential to affect all 64 residents who had their funds managed by the facility. The facility census was 100. Findings include: Review of the SRI #239603 Misappropriation Investigation Statement by the Administrator revealed on 09/25/23 he was updated by Corporate Controller #207 that there was a finding of misappropriation with additional checks written by Receptionist #206 from the resident trust account without supporting documentation. He stated the checks had his signature, which were forged. On 09/27/23 the facility restored all the funds to the appropriate resident trust accounts. Review of the Police Report #202301071 dated 09/26/23 at 2:37 P.M.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-17 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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, self-reported incident (SRI) review, and record review, the facility failed to implement the facility Abuse, Mistreatment, Neglect, Exploitation and Misappropriation policy and procedures to ensure residents and/or representatives were notified of misappropriation of resident funds. This affected 19 (Residents #3, #5, #6, #18, #21, 37, #41, #42, #43, #45, #51, #59, #60, #61, #63, #66, #101, #102 and #103) of 19 residents reviewed for misappropriation. The facility census was 100. Findings include: Review of the SRI #239603 Misappropriation Investigation Statement by the Administrator on 9/25/23 revealed he was updated by Corporate Controller #207 that there was a finding of additional checks written by Receptionist #206 from the resident trust account without supporting documentation. He stated the checks had his signature, which were forged. On 09/27/23 the facility restored all the funds to the appropriate resident trust accounts. There was no mention of the facility updating residents 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 · Ecited before2022-05-12 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and facility policy review the facility failed to ensure food items were stored appropriately in the nursing unit refrigerators to prevent contamination and/or spoilage. This affected two residents (Resident's #56 and #58) and had to potential to affect all residents who received oral intake. The facility identified four residents (Resident's #16, #31, #59, and #79) who had orders for nothing by mouth. The facility census was 104. Findings include: 1. On 05/10/22 at 9:34 A.M. observations of the nutrition room refrigerator revealed three unnamed and undated cartons of ice cream, one unnamed and undated box of waffles, and multiple unnamed and undated prepackaged meals. Interview on 05/10/22 at 9:34 A.M. with Registered Nurse (RN) #75 stated any food items in the nursing unit refrigerators should have a resident's name and the date the food was to be used or discarded by. RN #75 verified the three cartons of ice cream, the box of waffles, and the prepackaged meals should have had a resident's name and use by/discard date on them. 2. On 05/10/22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, staff interview, and policy review the facility failed to ensure Resident #75 had a clean sanitary environment. This affected one resident (Resident #75) of all 104 residents observed for environment. Findings include: Review of the medical record revealed Resident #75 was admitted to the facility 01/28/20. Diagnoses included chronic respiratory failure, convulsions, tracheostomy, dependent of respirator, gastrostomy, congenital malformation, asthma, malformation of corpus callosum, arthrogryposis multiplex congenita, severe intellectual disabilities, congenital malformation of peripheral vascular system, microcephaly, psychomotor deficit, spastic quadriplegic cerebral palsy, hypoxic ischemic encephalopathy, and hypothermia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #75 had severely impaired cognition. He required total assistance for all activities of daily living. Further review of the assessment revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-12 · 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 record review, observation, interviews, and policy review the facility failed to ensure medication error rate was less than 5%. The medication error rate was 12%. This affected one (Resident #75) of seven residents observed during medication administration. The facility census was 104. Findings include: Record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including legally blind and lagophthalmos of unspecified eye and eyelid. Review of Resident #75's orders dated 05/2022 revealed the resident was ordered Artificial tears solution 0.4% instill one drop in both eyes every two hours for dry eyes. May keep at beside. The Artificial tears were scheduled at midnight, 2:00 A.M., 4:00 A.M., 6:00 A.M., 8:00 A.M., 10:00 A.M., noon, 2:00 P.M., 4:00 P.M., 6:00 P.M., 8:00 P.M., and 10:00 P.M. The Lumify Solution 0.025% (decrease redness) was ordered to instill one drop in both eyes every six hours (midnight, 6:00 A.M., noon, and 6:00 P.M.) for red eyes. May keep at bedside. 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 · D2022-05-12 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and staff interview the facility failed to ensure laboratory tests were obtained as ordered for Resident #2. This affected one (Resident #2) of six residents reviewed for infection control. The facility census was 104. Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, adult failure to thrive, diabetes, chronic kidney disease, pacemaker, generalized anxiety disorder, hypothyroidism, atherosclerotic heart disease, and protein calorie malnutrition. Review of the physician's order dated 01/29/22 revealed Resident #2 received an order to obtain a stool for Clostridium Difficile (C-Diff) due to diarrhea. Further review of the record revealed the stool was never obtained. Interview on 05/12/22 at 10:11 A.M., Registered Nurse #104 verified there was no stool sent to the laboratory for Resident #2 to be tested for C-Diff and there was never no order obtained to discontinue the stool…
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 · D2022-05-12 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview the facility failed to honor the food preference for Resident #80. This affected one resident (Resident #80) of two reviewed for food. The facility census was 104. Findings include: Review of the medical record revealed Resident #80 was admitted to the facility on [DATE]. Diagnoses included herpes zoster, spondylosis, osteoarthritis, benign prostatic hyperplasia, obstructive and reflux uropathy, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, diabetes, vascular dementia, chronic kidney disease, peripheral vascular disease, atrial fibrillation, enterocolitis due to clostridium difficile, congestive heart failure, and anemia. Review of the food preferences and diet history dated 09/23/21 revealed Resident #80 had a dislike for scrambles eggs. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 had intact cognition. He required limited assistant with all activities of daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-12 · 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, review of the medical record, manufactures instructions, and staff interview the facility failed to clean the isolation room of Resident #80 with the appropriate disinfectant and failed to maintain appropriate infection control practice while performing tracheostomy care for Resident #75. This affected two residents (Resident's #75 and #80) of six residents reviewed for infection control. The facility census was 104. Findings include: 1. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE]. Diagnoses included herpes zoster, spondylosis, osteoarthritis, benign prostatic hyperplasia, obstructive and reflux uropathy, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, diabetes, vascular dementia, chronic kidney disease, peripheral vascular disease, atrial fibrillation, enterocolitis due to clostridium difficile, congestive heart failure, and anemia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2019-07-25 · 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 observation, record review, policy review and staff interview, the facility failed to ensure sanitary measures were followed during hydration pass and failed to maintain a comprehensive water management program to ensure residents were not exposed to Legionella. This had the potential to affect all 113 residents residing in the facility. Findings include: 1. Observation 07/24/19 at 7:56 P.M. of State Tested Nurse Aide (STNA) #542 revealed she was passing ice and filling cups with water. STNA #542 was removing a Styrofoam cup from the inside of the ice chest and filling it with ice using a scoop. STNA #542 was then dropping the scoop into the chest onto the ice before she closed the lid to take the Styrofoam cups into the room. The Styrofoam cups had black magic marker writing on the outside of the cups. Review of the facility's undated Serving Drinking Water policy included to roll the cart to the outside entrance of the residents room. Place current date and residents names on the Styrofoam cup. Take…
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 before2019-07-25 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had unrestricted access to the bathroom. This affected one (Resident #97) of two residents reviewed for dignity. The facility identified five residents with locked bathrooms (Resident #26, Resident #62, Resident #72, Resident #88 and Resident #97). The facility census was 113 residents. Findings include: Review of Resident #97's medical record revealed an admission date of 02/27/13 and diagnoses including congestive heart failure, chronic pain, adult failure to thrive, edema and protein-calorie malnutrition. Review of physician's orders revealed an order dated 06/10/19 for Resident #97's bathroom door to be locked at all times, as the resident was to use her call light to ask for assistance. An order dated 07/11/19 indicated Resident #97 was on a two-hour toileting schedule. An order dated 07/19/19 indicated Resident #97 could use the bathroom in her room with the assistance of two staff members. Review of an order dated…
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 · D2019-07-25 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure 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, interview and record review, the facility failed to ensure physical restraints were comprehensively assessed. This affected one resident (Resident #37) of two residents reviewed for physical restraints and had the potential to affect 10 additional residents identified as by the facility as having devices that could be considered restraints (Residents #25, #41, #43, #52, #80, #87, #95, #99, #347 and #358). The facility census was 113 residents. Findings include: 1. Review of Resident #37's medical record revealed an admission date of 06/02/18 and diagnoses including chronic obstructive pulmonary disease, muscle weakness, depression, dementia without behavioral disturbance and anxiety. Review of physician's orders revealed an order for a pummel cushion (a cushion with a foam piece that sticks upwards out of the seat of a wheelchair between a person's legs that prevents forward sliding in the wheelchair) dated 03/23/19. Review of an annual comprehensive Minimum Data Set (MDS) 3.0 assessment…
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 · D2019-07-25 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide written notifications to the residents and the residents' representatives of the reason for transfer of residents to the hospital. This affected three (Residents #77, #97, and #107) of three residents reviewed for hospitalization. Findings include: 1. Review of Resident #77's medical record revealed diagnoses including stroke, diabetes mellitus, vascular dementia and a history of sepsis. A nursing note dated 07/18/19 at 3:41 A.M. indicated at 10:00 P.M. Resident #77 had a medium emesis (vomit). The nurse attempted to administer Zofran (for nausea) but Resident #77 refused. At 3:30 A.M. Resident #77 had another emesis that was large and yellow/green in color. Resident #77's blood pressure was 185/106, pulse was 114, and temperature was 98.0 degrees Fahrenheit (F). Resident #77's oxygen saturation level was 95% (percent) on room air. Resident #77's son requested she be sent to the emergency room for evaluation. A nursing note dated…
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 before2019-07-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interview, the facility failed to administer a treatment to Resident #33 as ordered. This affected one resident (Resident #33) of four reviewed for non-pressure skin conditions. Finding include: Review of the medical record review revealed Resident #33 was admitted to the facility on [DATE] with the diagnoses of dementia, hypertension, osteoporosis, atria fibrillation, chronic obstructive pulmonary disease, severe protein-calorie malnutrition, edema, vitamin D deficiency, rheumatoid arthritis, dysphagia, history of falling, pseudo bulbar affect, major depressive disorder, peripheral vascular disease, and Alzheimer's disease. Review on the quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #33 had intact cognition, required extensive assistance of one staff member for eating and did not have a weight loss. Observation on 07/22/19 at 1:54 P.M. and throughout the survey Resident #33 had dry, red peeling skin around her mouth and nose. An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-07-25 · 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, medical record review and staff interview, the facility failed to implement physician orders for pressure ulcer prevention and treatment for one (Resident #358) of five residents reviewed for pressure ulcers. The facility census was 113. Findings include: Review of Resident #358's medical record revealed an admission date of 07/13/19 with diagnoses including a malignant neoplasm of the brain, memory deficit following a stroke, low back pain and urinary tract infection. Skin and wound evaluations dated 07/13/19 and 07/23/19 indicated Resident #358 had unstageable pressure injuries (ulcers with obscured full-thickness skin and tissue loss) on the coccyx, left buttock and right buttock. a). On 07/13/19 an order was written for a gel cushion when out of bed. An acute care plan indicated Resident #358 was to have a ROHO cushion (a cushion to decrease the amount of pressure on the sitting area through a patented technology of interconnected neoprene air cells that increase and decrease in air volume to match an individuals contours) when out of bed. On 07/22/19 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-07-25 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, interview and review of information from the manufacturer of tube feed solution, the facility failed to administer tube feeding solution in a method which would reduce the risk of contamination. This affected one (Resident #76) of one resident reviewed for tube feedings. The facility identified six residents who received tube feedings. Findings include: Review of Resident #76's medical record revealed diagnoses including gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), stroke and difficulty swallowing. Resident #76 had a physician's order for Diabetisource AC (tube feeding supplement) to be administered through the feeding tube at 63 milliliters per hour (ml/hr) on a continuous basis. On 07/24/19 at 8:22 A.M., Resident #76 had a kangaroo bag (a disposable bag into which tube feed solution or water can be dispensed for delivery into the gastrostomy) with tube feed solution (type of solution not written on the bag) hanging on a pole with the tube feed pump. The bag 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.
- Potential for harm · D2019-07-25 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
2. Review of Resident #10 revealed an admission date of 01/21/14 with diagnoses including dementia, hypertension, Alzheimer's disease, heart failure, peripheral vascular disease, depression, anxiety, atrial fibrillation, osteoporosis, gastro-esophageal reflux disease, hyperlipidemia, Vitamin D deficiency, chronic obstructive pulmonary disease, sinusitis and cerebrovascular disease. Review of the 04/08/19 significant change Minimum Data Set (MDS) 3.0 assessment revealed the resident was independent for daily decision making and medications included antianxiety, antidepressant, anticoagulant and diuretic. A pharmacy recommendation on 03/20/19 revealed the resident had been on Floraster, a probiotic, for at least two years. The recommendation stated Would you please evaluate the continued need for this medication and consider discontinuing, if clinically relevant? The physician disagreed by just saying don't. Interview 07/25/19 at 11:23 A.M. with RN #609 revealed the physician did not give rationale when disagreeing with the 03/20/19 pharmacy recommendation. Based on 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 · D2019-07-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure medical necessity of an anti-anxiety medication ordered for one (Resident #76) of six residents reviewed for unnecessary medications. The facility census was 113. Findings include: Review of Resident #76's medical record revealed an admission date of 04/18/19. Diagnoses included chronic obstructive pulmonary disease, stroke and dementia. An admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #76 was rarely/never able to make himself understood and rarely/never understood others. Resident #76 was assessed with short and long term memory problems and severely impaired cognitive skills for daily decision making. During a monthly medication review conducted 04/25/19, the pharmacist addressed Resident #76's order for Ativan (anti-anxiety) to be administered on an as necessary basis and requested the physician re-evaluate its use after 14 days. On 05/06/19, an area for the physician response revealed an order for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-07-25 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, meal ticket review, resident and staff interviews, the facility failed to honor food preferences. This affected two residents (Resident #16 and Resident #33) of six residents reviewed for nutrition. Findings Include: 1. Review of the medical record review revealed Resident #33 was admitted to the facility on [DATE] with the diagnoses of dementia, hypertension, osteoporosis, atrial fibrillation, chronic obstructive pulmonary disease, severe protein-calorie malnutrition, edema, vitamin D deficiency, rheumatoid arthritis, dysphagia, history of falling, pseudo bulbar affect, major depressive disorder, peripheral vascular disease, and Alzheimer's disease. Review on the quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #33 had intact cognition, required extensive assistance of one staff member for eating and did not have a weight loss. An observation on 07/23/19 at 8:23 A.M. Resident #33 was in the main dining not eating her meal. She received a breakfast…
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
$25,495 in federal fines across 1 penalty.
- $25,495 — penalty dated 2026-04-01
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BERARDINO, NICHOLAS | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 25% | since 02/21/2018 |
| CILONE, JOSEPH | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 25% | since 10/01/2009 |
| HUBER, MICHAEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | 25% | since 10/01/2009 |
| LUMENT REAL ESTATE CAPITAL LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 12/01/2018 |
| PETROZZI, LARRY | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | — | since 10/01/2009 |
| JCTH HOLDINGS, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/09/2025 |
| HOWELL, STACEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/22/2016 |
| HUSAIN, MUMTAZ | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/09/2025 |
| MCINTOSH, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/07/1997 |
| CALCUTTA NURSING HOME, INC | Organization | ADP OF THE SNF | — | since 05/24/1994 |
CMS files one row per role, so the 31 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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.
About 79% 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 $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 22% 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
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 365987. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-06, 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.