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Altercare Cambridge Inc.

66731 Old Twenty-One Road, Cambridge, OH 43725 · For profit - Corporation · 50 certified beds · (740) 432-7717 Medicare & Medicaid certified

Call the home — (740) 432-7717 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0605, F0610) — most recent Jan 20262 actual-harm citations
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)
  • no federal fines or payment denials on record
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score

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

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
65021 Old Twenty One Rd · (740) 439-4622 · Call to confirm hours
Pharmacy
1330 Clark St · (740) 255-5844 · Call to confirm hours
Grocery
66611 8th St Rd · (740) 260-2531 · Call to confirm hours
Park
1101 McFarland Dr · (740) 432-3287 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased0.0%5.3%15.4%check this — see note marked star below the table
Long-stay residents who lose too much weight5.4%6.2%5.4%typical
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 infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms72.3%30.1%6.5%worse 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 injury1.3%3.2%3.3%better
Long-stay residents whose ability to walk worsened4.1%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication35.1%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers1.9%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control15.6%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table0.0%8.8%17.1%check this — see note marked star below the table
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine97.0%75.6%79.4%better
Short-stay residents rehospitalized after admission22.8%24.9%22.6%typical
Short-stay residents with an outpatient ER visit8.5%12.9%12.0%better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

50.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 121 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.7%U.S. median 51.5%
Got home and stayed home
15.5%U.S. median 10.7%
Went back to hospital
72.9%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 72.9% 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 48 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 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.7%CMS range 41.0–59.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF15.5%CMS range 11.9–19.110.7%Oct 2022–Sep 2024worse 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 discharge72.9%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 discharge79.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge70.8%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.6%CMS range 3.3–11.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.911.02Oct 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

0.87
RN hours/ resident / day
0.73
LPN hours/ resident / day
2.03
Aide hours/ resident / day
3.64
Total nurse hours/ resident / day
0.59
RN hoursweekends
39.1%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 50 beds and averages 46.5 residents a day — about 93% occupied, or roughly 4 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 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.87 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.18 hrs/resident/day on weekends vs 3.82 on weekdays — 17% thinner on weekends. RN hours go from 0.99 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.

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

Inspection trend

7
deficiencies at the latest standard inspection (2026-01-07)
4
at the previous standard inspection (2024-09-05)

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.

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.

27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · Gcited before2026-01-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, hospital record review, Self-Reported Incident (SRI) review, facility policy review, and interviews, the facility failed to timely identify and address a resident's change in condition following a mechanical lift transfer. This affected one resident (#55) of three residents reviewed for hospitalizations. The facility census was 47. Actual harm occurred on 11/16/25 when Resident #55, who was severely cognitively impaired and required staff assistance for activities of daily living, slammed her body down into a sit-to-stand (mechanical lift) device on her right side and back due to an episode of increased weakness. The facility staff failed to notify the resident's medical provider of the change in condition including the episode of weakness and slamming of the right side of her body and back down into the sit-to-stand device. The resident was assessed at the time with no injuries noted. Following the initial assessment, there was no documented evidence of ongoing monitoring…

    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
  • Actual harm · Gcited before2026-01-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, hospital record review, policy review and interview, the facility failed to implement a comprehensive and individualized pressure ulcer program to timely identify, treat and/or prevent a decline of pressure ulcers. This affected two residents (Resident #42 and #07) of three residents reviewed for pressure ulcers. Actual Harm occurred on 12/06/25 when Resident #42, who had been identified at risk for pressure ulcer development and required maximum staff assistance for bed mobility, returned from the hospital with a red and blanchable area to his (unidentified) buttock without evidence of a comprehensive skin assessment or implementation of pressure relieving interventions or wound treatment to prevent decline in the pressure ulcer. On 12/11/25, a skin assessment identified a new Stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed) pressure ulcer to the coccyx without implementation of pressure relieving…

    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 · D2026-01-07 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Review of the medical record, review of the facility policy, and interview with staff the facility failed to ensure as needed psychotropic medications were not used beyond 14 days without rationale. This affected two residents (#1, #51) reviewed for unnecessary medications. Findings include:1.Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included sepsis, pneumonia, dysphagia, end stage renal disease, chronic respiratory failure with hypoxia, congestive heart failure, hypertension, rheumatoid arthritis, macular degeneration, vitamin D deficiency, exocrine pancreatic insufficiency, depression, hypertensive heart, chronic kidney disease, osteoarthritis, and atrial fibrillation. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition, had no behaviors, and was not on any antipsychotic medications. Review of the December 2025 physician's orders revealed Resident #1 had an order for lorazepam (benzodiazepine…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-07 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, self-reported incident (SRI) review, facility investigation review, facility policy review, and interview, the facility failed to complete a thorough investigation following an allegation of abuse. This affected one (#55) of one resident reviewed for abuse. The facility census was 47.Findings include: Review of the Self-Reported Incident (SRI) #267738 submitted to the Ohio Department of Health (ODH) on 11/19/25 revealed an investigation was initiated by the facility for an allegation of physical abuse. The SRI revealed Resident #55 was discharged to the hospital on [DATE] following a non-SRI related critical lab finding. Resident #55's daughter contacted the facility on 11/19/25 to report the resident had bruising on her right hip and possibly small bruises on her back. There was no alleged perpetrator. Staff were interviewed and it was revealed that over the weekend 11/15-11/16/25 staff had attempted to utilize a mechanical lift known as a sit-to-stand to safely transfer 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to provide a person-centered, comprehensive care plan, developed and implemented to meet the preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. This affected two residents (#37, #48) of five residents reviewed for care plans. The facility census was 47.Findings include:1. Review of the medical record for Resident #37 revealed she was admitted to the facility on [DATE]. Diagnoses included osteomyelitis; muscle weakness; need for assistance with personal care; methicillin resistant staphylococcus aureus; bacteremia; noncompliance with other medical treatment and regimen; Type 2 diabetes mellitus with diabetic polyneuropathy; depression; chronic obstructive pulmonary disease; anxiety disorder; hyperlipidemia; hypokalemia; anemia; acute kidney failure; hyperglycemia; and gastroesophageal reflux disease without esophagitis. Review of a Minimum Data Set (MDS) version 3.0, dated 11/18/25, for 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 · Dcited before2026-01-07 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review and review of facility policy, the facility failed to ensure medications were properly stored. This affected one resident (#27) of one resident reviewed for medication storage. The facility census was 47.Findings include:Review of the medical record for Resident #27, revealed an admission date of 08/19/21. Diagnoses included: spinal stenosis, lumbar region without neurogenic claudication, Alzheimer's disease, dementia and major depressive disorder.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14. Observation on 12/22/25 at 10:23 A.M. revealed a medicine cup containing four pills on Resident #27's bedside table. Resident #27 stated she does not know how long they have been there.Review of the physician orders revealed Resident #27 did not have an order to self-administer medications or for medications to be left at bedside.Interview on 12/22/25 at 10:25 A.M. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-07 · 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 record review, self reported incident review, and interview the facility failed to ensure the incident log was complete and accurate for a resident fall and failed to ensure a resident's medical record was complete. This affected one resident (#55) of two residents reviewed for accidents. The facility census was 47.Findings include:Review of the medical record for Resident #55 revealed an admission date of 09/24/25. Diagnoses included infection following a procedure surgical site, cellulitis of left lower limb, muscle weakness, dysphagia, cognitive communication deficit, repeated falls, fracture of left femur, acute respiratory failure with hypoxia, anemia, and anxiety. Review of a Minimum Data Set (MDS) version 3.0, dated 10/13/25, revealed a Basic Interview for Mental Status (BIMS) of seven on a 0-15 scale. A BIMS score of seven would indicate severe problems with thinking and memory. It also indicated the resident needed assistance with all activities of daily living (ADLs).Review of a 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-26 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the job descriptions, review of the employee handbook, review of a self-reported incident investigation, review of timed stamped and dated photographs, review of the facility assessment, review of time sheets, interviews, policy review, and review of the Nurse Practice Act, the facility failed to ensure care and services were provided within acceptable standards of quality when Licensed Practical Nurse (LPN) #133 was observed pre-pouring resident medications and also observed sleeping multiple times throughout the shift. This had the potential to affect the residents residing on the Rodeo Unit where LPN #133 was working. The facility census was 48.1. Review of Licensed Practical Nurse (LPN) #133's timecard dated 11/06/25 and 11/07/24 revealed LPN #133 clocked in at 11:54 P.M. on 11/06/25 and clocked out at 6:12 P.M. on 11/07/24. The LPN worked 17.75 hours.Review of photographs dated 11/07/24 at 4:33 A.M., revealed LPN #133 standing in front of medication cart with the card drawer open. There were approximately nine medication cups with several loose pills in 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-26 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents received timely pain management. This affected one (Resident #50) of three residents reviewed for pain management. The census was 48. Findings include: Record review revealed Resident #50 admitted to the facility on [DATE] with diagnoses including anemia, hypertension, thyroid atrophy, hypomagnesemia, anxiety, and femur fracture with surgical intervention.Review of Resident #50 admission Minimum Data Set (MDS) section C for cognition revealed a Brief Interview for Mental Status Score of 15, indicating Resident #50 was cognitively intact.Review of MDS section J for health conditions revealed Resident #50 was receiving a scheduled pain medication regimen, and received as needed (PRN) pain medication.Review of Resident #50 care plan completed on 06/11/25 revealed Resident #50 has a left hip surgical wound. Goals include resident will have controlled pain and a level of comfort maintained daily. Interventions include to administer pain…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-31 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    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, policy review and interview, the facility failed to maintain resident dignity for Resident #100. This affected one resident (#100) of three sampled residents. The facility census was 49. Findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE] with a history of urinary tract infections and discharged to the hospital on [DATE]. The resident returned to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies, dementia, prostate cancer, obstructive uropathy, and an indwelling urinary catheter. Review of the 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 was cognitively intact for daily decision-making and utilized an indwelling urinary catheter. Review of the Physician Orders dated 12/30/24 revealed Resident #100 was ordered a suprapubic catheter to straight drainage. On 12/30/24 at 9:19 A.M., observation revealed Resident #100 and Resident #83 were sitting in…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-05 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) document accurately reflected medications and a psychiatric hospitalization. This affected one (Resident #37) of four residents reviewed for PASRR documents. The census was 46. Findings Include: Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, Alzheimer's disease, major depressive disorder, delusional disorder, dementia with psychotic disturbance, and panic disorder. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 07/19/24, revealed the resident was severely cognitively impaired and received an anti-anxiety medication. Review of Resident #37's PASRR document, dated 08/26/24, revealed under Section E, no anti-anxiety medication. Review of the resident's physician orders, dated 03/29/24, revealed the order for Xanax 0.5 milligrams (mg) to be administered three times per day.…

    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 · D2024-09-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident interview, record review, policy review and staff interview, the facility failed to ensure oxygen tubing was changed weekly and documented as administered in the medical record. This affected one (Resident #8) of two residents reviewed for supplemental oxygen use. The facility census was 46. Findings include: Observations of Resident #8 on 09/03/24 at 9:26 A.M. revealed the resident lying in bed. Supplemental oxygen was supplied by an oxygen concentrator (machine that separates nitrogen from atmospheric air delivering 95% pure oxygen) via a nasal cannula. No evidence of any date to the tubing and nasal cannula was observed. Additional observations of Resident #8 on 09/03/24 at 3:58 P.M., 09/04/24 at 7:38 A.M. and 09/04/24 at 12:05 P.M. revealed supplemental oxygen in use by Resident #8 with no date on the tubing. Observation on 09/05/24 at 9:50 A.M. revealed Resident #8 sitting in her recliner and supplemental oxygen lying on her bed with the tubing undated. Interview with Resident #8 on 09/05/24 at 9:50 A.M. revealed that she uses the supplemental…

    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
Show the remaining 15 citations
  • Potential for harm · D2024-09-05 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a meal ticket, observation, resident interview, staff interview, and policy review, the facility failed to ensure there was consistent communication between the facility and the dialysis center regarding a resident's hemodialysis treatments. They also failed to ensure the medical record accurately reflected the resident's current order for a fluid restriction and staff were knowledgeable about the resident's need for a fluid restriction as ordered for end stage renal disease. This affected one (Resident #19) of one resident reviewed for dialysis. Findings include: 1 a.) Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, dependence on renal dialysis, pulmonary hypertension, and congestive heart failure. Review of Resident #19's physician's orders revealed the resident had an order for dialysis treatments every Monday, Wednesday, and Friday. The order originated on 08/19/23. Review…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review and staff interview, the facility failed to follow appropriate transmission based precautions for a resident on contact precautions. The affected one (Resident #253) of two residents identified on transmission based precautions. The facility census was 46. Findings include: Review of Resident #253's medical record revealed an admission date of 08/30/24 with diagnoses that included enterocolitis due to clostridium difficile, sepsis, pneumonia and chronic obstructive pulmonary disease. Physician's orders upon admission indicated Resident #253 required contact transmission based precautions and resident to remain in his room related to signs of symptoms of a highly transmissible disease or epidemiologically significant pathogen. Observation on 09/04/24 at 2:20 P.M. revealed Activity Coordinator (AC) #192 in Resident #253's room. A sign was posted on Resident #253's door frame indicating he was on contact precautions and a cart containing personal protective supplies was noted below the sign and outside the resident's room door. AC #192 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 · D2024-04-17 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 and interview with the staff the facility failed to ensure that private identifiable medical information for Resident #10 was not visible on the computer screen and left unattended by staff. This affected one resident ( Resident #40) of four residents observed for medication administration. The facility census was 49. Findings included: Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included muscle weakness, chronic obstructive pulmonary disease, diabetes, hypertension, rheumatoid arthritis, major depressive disorder, anxiety disorder, respiratory failure, polyneuropathy, glaucoma, vitamin D deficiency, congestive heart failure, low back pain, irritable bowel syndrome, ulcerative colitis, diverticulitis, intervertebral disc degeneration, chronic pain syndrome, and adult failure to thrive. Observation on 04/16/24 at 7:22 A.M. revealed the facility medication cart was sitting outside room [ROOM NUMBER] 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-17 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record and interview with staff the facility failed to ensure medications were not left unattended on top of the medication cart and failed to ensure the medication cart was locked while unattended. This had the potential to affect three residents ( Resident #33, #41, and #43) out of 21 who were cognitively impaired and independently mobile on the Rodeo Unit. The facility census was 49. Findings included: Observation on 04/16/24 at 7:22 A.M. revealed the facility medication cart was sitting outside room [ROOM NUMBER] unlocked and with a plastic medicine cup with 12 tablets in it on the top of the cart. The medication in the medication cup was for Resident #40 and contained; one tablet of aspirin (analgesic) 81 mg, one tablet of Buspar (anti-anxiety) 15 mg, one tablet of Carafate (gastrointestinal agent) 1 gram, one tablet of vitamin D 3 ( vitamin) 5000 units, one tablet of Dicyclomine (anti-cholinergic) 20 mg, one tablet of Duloxetine (anti-depressant) 60 mg, one…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-17 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview with staff, and review of facility policy the facility failed to ensure staff preformed proper hand hygiene during medication administration. This affected two resident ( Resident #34 and #45) out of four observed for medication administration. The facility census was 49. Findings included: Observation on 04/16/24 at 7:27 A.M. revealed Registered Nurse #110 administered medication to Resident #39 then proceeded to return to the medication cart without washing her hands and prepared medication for Resident #34. At 7:33 A.M. RN #110 administered those medication to Resident #34. She then returned to the medication cart without washing her hands. At 7:45 A.M. RN #110 prepared and administered medications for Resident #45 without washing her hands prior however she did wash her hands after she administered the medication. On 04/16/24 at 7:50 A.M. an interview with RN #110 revealed she had not washed her hands after administering medication to Resident #39, before and after administering medication to Resident #34 and prior to administration of medication…

    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 · D2024-01-31 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a facility investigation, review of operating instructions of an enteral feeding pump, resident interview, and staff interview, the facility failed to ensure a resident received an enteral tube feeding at the rate ordered by the physician and staff adequately monitored the flow rate of the enteral feeding when assessing the resident for complications associated with his peg tube. This affected one resident (#15) of one resident reviewed for enteral tube feedings. Findings include: A review of Resident #15's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included dysphagia and gastrostomy status. A review of Resident #15's physician's orders revealed he had an order to receive an enteral feeding (nutritional supplement that was provided through a feeding tube directly into the stomach that was surgically placed through the abdominal wall) of Isosource 1.5 cal at 55 milliliters/ hour (ml/ hr) on a continuous basis. The order was initiated on…

    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 · F2022-08-11 · 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 and interview, the facility failed to maintain the kitchen in a sanitary condition. This had the potential to affect all the residents in the facility except Residents #29 and #93 who did not receive nutrition from the kitchen. The facility census was 43. Findings include: Initial tour of the kitchen 08/01/22 at 8:45 A.M. revealed the following; 1. The ice machine had brown slimy film on the lip of the shoot. The slimy film wiped off with a paper towel. There was dried white debris around the door seal and lid. 2. In the dry storage, breadcrumbs were opened and not dated. 3. The vents above the range top and grill were dusty. There were grease traps on each side of the vents. The trap on the left had blowing dust stringing out an inch long. 4. The ansel system above the rangetop and griddle had dust going up the piping and on the red spray covers. 5. The lights above the griddle and range cooking surface were dusty. 6. The tops of the convention oven and the steamer were dusty, with a greasy texture and crumbs. 7. The reach in refrigerator had six rusty shelves.…

    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 · Fcited before2022-08-11 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy and interview, the facility failed to ensure personal protective equipment (PPE) and surfaces were sanitized when leaving isolation rooms, isolation linens and personals were washed in a sanitary manner, and a urinary collection bag was maintained off the floor. This affected Residents #17, #25, #28, #34, and #92. This had the potential to affect all the residents in the facility. Findings include: 1. Observation 08/01/22 12:05 PM of the lunch meal revealed State Tested Nurse Aide (STNA) #46 gowned, gloved and had an N-95 mask and goggles on when she delivered a tray to Resident #28 (this resident was in quarantine for exposure to COVID-19). Upon exiting the room, STNA #46 removed the PPE, except for goggles. STNA #46 used hand sanitizer and donned another N-95 mask, walked down the hall, and turned right down the hall. STNA #46 did not sanitize her goggles after leaving the quarantine room. Interview 08/01/22 at 12:09 P.M. with STNA #46 verified she did not clean her goggles when…

    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 · D2022-08-11 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interview, the facility failed to ensure care plans were revised to reflect new fall prevention interventions added after falls occurred. This affected two (Resident #5 and #28) of four residents reviewed for falls. Findings include: 1. A review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included seizure disorder, congestive heart failure, history of a stroke with hemiparesis (weakness) and hemiplegia (paralysis) affecting the right dominant side, dementia with behavioral disturbances, muscle weakness, abnormalities of gait and mobility, difficulty walking, unsteadiness on feet, need for assistance with personal care, abnormal posture and repeated falls. A review of Resident #5's quarterly Minimum Data Set (MDS) assessment completed on 04/19/22 revealed the resident did not have any communication issues and his cognition was moderately impaired. He was not known to have any behaviors but was known to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-08-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure timely intervention for constipation and assessment and treatment orders for a leg wound. This affected three (Resident's #16, #19 and #28) of 15 residents reviewed. Findings include: 1. Review of Resident #16's medical record revealed a 10/29/21 admission with diagnoses including cachexia, hypertension, hypothyroidism, gastro-esophageal reflux disease, vitamin D deficiency, osteoarthritis, diverticulitis, slow transit constipation, mild protein calorie malnutrition, and altered mental status. Review of a 11/19/21 plan of care for constipation related to medications and decreased mobility included the resident will have a soft formed bowel movement at least every three days. Interventions included to administer medications as ordered and observe for bowel movement every three days. Review of the 05/16/22 Significant Change MDS revealed the resident was moderately impaired for daily decision making, extensive assist of two for bed mobility, transfer, did not walk, extensive assist of one for dressing,…

    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 before2022-08-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and policy review, the facility failed to ensure pressure ulcers were adequately assessed to identify the correct staging of the pressure ulcer, failed to ensure a laboratory test and supplements recommended by the wound physician were implemented for wound healing, and a resident identified as being at risk for pressure ulcers had appropriate skin prevention interventions in place to help reduce the risk of pressure ulcers from developing. This affected two (Resident #35 and #93) of three residents reviewed for pressure ulcers. Findings include: 1. A review of Resident #35's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included a fracture of the right femur at the femoral neck, a history of a stroke with hemiparesis and hemiplegia of the right dominant side, muscle weakness, and difficulty walking. The resident was admitted to the facility with a stage II pressure ulcer (a pressure ulcer that presents as a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-11 · 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 observation, record review, policy review, and staff interview, the facility failed to have fall interventions in place. This affected three residents (#5, #10 and #28) of four residents reviewed for falls. Findings include: 1. Review of Resident #10's medical record revealed a 09/18/21 admission with diagnoses including metabolic encephalopathy, syncope and collapse, acute respiratory disease, muscle weakness, difficulty in walking, muscle wasting and atrophy, Type 2 diabetes mellitus with hyperglycemia, cardiac arrhythmia's, hypertension, Vitamin D deficiency, hypocalcemia, benign prostatic hyperplasia, emphysema, major depressive disorder, anxiety disorder, diverticulosis of intestine, and irritable bowel syndrome. The resident had a 10/12/21 risk for fall plan of care related to behaviors, history of falls, medications including anxiolytic's, antidepressants, antihypertensive's, and diabetes. Interventions included on 02/14/22 to place a sign in room to remind to get assistance with footwear,…

    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 · D2022-08-11 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to obtain laboratory testing as ordered to monitor medication use. This affected two Residents (#19 and #31) of five residents reviewed for unnecessary medication. Findings include: 1. Review of Resident #19's medical record revealed a 06/27/21 admission date with diagnoses including peripheral vascular disease, diabetes, and anemia. Physician orders included atorvastatin 40 mg daily for high cholesterol and magnesium oxide 400 mg twice a day, both ordered 06/27/21. Review of a 01/04/22 pharmacy recommendation included to add a lipid panel, Vitamin D level and Magnesium yearly. The recommendation was accepted on 01/06/22 to add the orders to the February, 2022 laboratory draw with the HGBA1C. Review of the physician orders revealed the order was entered 01/06/22 for a lipid profile, Vitamin D level and Magnesium on the second monday of every 12th month. Review of the 05/31/22 annual MDS revealed the resident was independent for daily decision making, required extensive assist of one for bed mobility, transfer,…

    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 · D2022-08-11 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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, policy review, and interview, the facility failed to ensure flu and pneumococcal vaccinations were offered. This affected one resident (Resident #19) of five residents reviewed for vaccines. Findings include: Review of Resident #19's medical record revealed a 06/27/21 admission date with diagnoses including peripheral vascular disease, diabetes, and anemia. Review of Resident #19's 05/31/22 annual MDS revealed the resident was independent for daily decision making, required extensive assist of one for bed mobility, transfer, toileting, personal hygiene and did not walk. The resident received ointment to areas other than feet. Review of Resident #19's Preventative Health Care included the resident had a flu vaccine prior to admission [DATE]. There was no evidence the facility offered a flu vaccine after the 06/27/21 admission. The facility had no information for Resident #19 on a past history of receiving the pneumococcal vaccine. There was no evidence the facility offered a pneumococcal…

    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
  • No harm found · C2024-12-31 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, BIPA (Benefits Improvement and Protection Act) Report review, daily census report review, and interview, the facility failed to post accurate nurse staffing information as required. This had the potential to affect all 49 residents residing within the facility. Findings include: On 12/30/24 at 9:07 A.M., observation of the reception area revealed a BIPA Report dated 12/30/24 indicating the current census was 46. At 9:09 A.M., an interview with the Administrator stated he would need to double-check the census as the BIPA Report could change due to, he received this report from the corporate office. The Administrator stated the BIPA report currently posted had been printed out on 12/27/24 to cover through the weekend, including this one. BIPA Report postings were observed at the reception desk and both nursing stations. On 12/30/24 at 4:15 P.M. observation of the posted BIPA Reports dated 12/30/24 at two nursing stations and the reception area revealed the facility census was 46. Review of the Daily Census Report dated 12/30/24 revealed the facility census 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ALTERCARE — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.3+0.7 vs chain
Health inspection 3 of 52.7+0.3 vs chain
Staffing 3 of 52.3+0.7 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 21 homes this chain runs (chain average 3.3★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
TSG NURSING CENTERS, INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 06/01/2018
GERALD F SCHROER DYNASTY TR UA 12312009 FBO ANDREW M SCHROEROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/01/2018
GERALD F SCHROER DYNASTY TR UA 12312009 FBO GERALD F SCHROER JROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/01/2018
GERALD F SCHROER DYNASTY TR UA 12312009 FBO MATTHEW SCHROEROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/01/2018
GERALD F SCHROER DYNASTY TR UA 12312009 MARGARET S GOODMANOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/01/2018
SUSANNE SCHROER DYNASTY TRUST U/AOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/01/2018
THE SCHROER GROUP, INC.Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/01/2018
MOCK, DOUGLASIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 09/20/2021
FILM, GEORGEIndividualCORPORATE OFFICERsince 06/01/2018
GOODMAN, JOHNIndividualCORPORATE OFFICERsince 06/01/2018
JOHNSON, KATHYIndividualCORPORATE OFFICERsince 06/01/2018
NUTTER, ORIANIndividualCORPORATE OFFICERsince 10/01/2020
ALTERCARE OF OHIO, INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 06/01/2018

CMS files one row per role, so the 14 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

8 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.

$4.9M
Net patient revenuemost recent cost report
-0.3%
Operating marginrevenue minus expenses
$246K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 14%Other / private 27%

This home reported $246K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$297per resident / day
operating cost
$9,030per month
≈ monthly operating cost
$296per 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 366128. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-07, 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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