Canfield Acres LLC DBA Windsor House At Canfield
6445 State Route 446, Canfield, OH 44406 · For profit - Corporation · 96 certified beds · (330) 967-4080 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0567)
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 34% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.3% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 8.3% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.0% | 0.4% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 3.6% | 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 | 5.1% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 8.7% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 14.2% | 25.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 51.0% | 94.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 2.4% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.9% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.0% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 31.6% | 75.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 29.9% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 22.3% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 4.76 | 1.73 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 5.08 | 1.80 | 1.80 | worse |
‡ 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.
55.1% 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 184 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 37.8% 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 82 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 0.40 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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 | 55.1%CMS range 46.7–62.9 | 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 | 10.2%CMS range 7.0–13.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 37.8% | 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 | 23.2% | 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 | 24.4% | 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 | 96.5% | 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 | 97.9% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 1.7% | 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 | 3.5% | 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 | 7.6%CMS range 4.6–11.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 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 96 beds and averages 69.8 residents a day — about 73% occupied, or roughly 26 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 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 3.29 hrs/resident/day on weekends vs 3.87 on weekdays — 15% thinner on weekends. RN hours go from 0.77 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · D2026-01-08 · 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, interview, record review and review of facility policy, the facility did not ensure Resident #32 was treated with respect and dignity when in need of assistance by staff. This affected one resident (#32) of one resident reviewed for assistance with activity of daily living. The facility census was 68. Findings include:Review of the medical record for Resident #32 revealed an admission date of 03/05/25 with diagnoses including contracture of an unspecified joint, muscle wasting and atrophy, lack of coordination, hypertension, difficulty in walking, and muscle weakness. Review of the physician's orders for Resident #32 identified orders for a mechanical lift for all transfers with an effective date of 03/05/25.Review of the self-care plan of care, initiated 03/13/25, indicated Resident #32 was at-risk for a self-care deficit. Interventions included, but were not limited to, remind resident to use call light and ask for assistance before self-transferring (03/13/25), up to wheelchair as tolerated (03/13/25), and use assistive devices as indicated (03/13/25).…
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 · D2026-01-08 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview and review of the facility policy, the facility failed to ensure authorizations for resident funds were witnessed as required. This affected one resident (#37) of five residents reviewed for resident funds. Facility census was 68.Review of Resident #37's medical record revealed an admission date of 02/16/24 and diagnoses including anemia, vitamin D deficiency, subclinical iodine-deficiency hypothyroidism, severe protein-calorie malnutrition and malignant neoplasm of rectum. Resident #37 was her own responsible party and per the quarterly Minimum Data Set (MDS) 3.0 assessment on 12/29/25, Resident #37 was cognitively intact. Review of a choice of resident funds disposition form, signed electronically by Resident #37's brother on 02/19/24, revealed an area on the form for a witness signature which was left blank. Interview on 01/06/26 at 2:29 P.M. with Business Office Manager (BOM) #383 revealed the resident funds authorizations were electronically signed and she was not sure how the witnessing of the authorization worked with the electronic…
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 before2026-01-08 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, interview, review of the facility's self-reported incidents (SRI) of abuse, and review of facility policy, the facility failed to report to the state agency a resident to resident verbal abuse incident. This affected two residents (#29 and #59) of two reviewed for abuse. The facility census was 68. Findings include:1. Review of the medical record for Resident #29 revealed an admission date of 09/20/24 with diagnoses including history of stroke, expressive language disorder, metabolic encephalopathy, anxiety disorder, and vascular dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/20/25, revealed Resident #29 was cognitively intact. Review of Resident #29's progress note dated 11/18/25 at 5:15 P.M. revealed another resident thought Resident #29 was his sister. Review of Resident #29's progress notes for December 2025 revealed there was no documentation of any incidents occurring between Resident #29 and Resident #59. On 01/05/26 at 3:06 P.M., an interview was attempted with Resident #29, however, Resident #29 was not…
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 before2024-10-11 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility self-reported incident (SRI) review, interviews, and facility policy review, the facility failed to timely report an allegation of physical abuse to the state agency. This affected two residents (Resident #32 and Resident #65) out of three residents reviewed for abuse. The facility census was 63. Findings include: 1. Review of the medical record for Resident #32 revealed an admission date of 11/02/21. Diagnoses included chronic diastolic (congestive) heart failure, major depressive disorder, anxiety disorder, and exudative age-related macular degeneration of the right eye. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was moderately impaired cognitively with no behaviors or signs or symptoms of delirium and required supervision or touch assistance from staff for sit to stand, transfers, and walking ten feet. Interview on 10/11/24 at 5:56 A.M. with Resident #32 revealed there had been an incident where another resident (Resident #33),…
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 · D2024-06-25 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure Resident #61's hospice care plan and actual skin impairment care plan were in place and updated. This affected one resident (#61) out of three residents reviewed for care plans. The facility census was 60. Findings include: Review of the closed medical record revealed Resident #61 was admitted to the facility on [DATE] and expired on [DATE]. Diagnoses included but was not limited to dementia unspecified, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, kidney disease, urine retention, colon cancer, malnutrition. Resident #61 was admitted to hospice on [DATE]. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #61 was cognitively intact. The assessment noted he was at risk for pressure ulcers and had no pressure ulcers. Review of the care plan dated [DATE] revealed the care plan was not updated to include hospice admission on [DATE], three new areas of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-25 · 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 record review, interview, and facility policy review the facility failed to appropriately monitor Resident #61 after a significant change in condition related to signs of urinary tract infection (UTI). This affected one resident (#61) of three residents reviewed for a change of condition. The facility census was 60. Findings include: Review of the closed medical record for Resident #61 revealed an admission date of 09/18/23 and an expiration date of 04/26/24. Diagnoses included dementia, kidney disease, urinary retention, colon cancer, and malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was moderately cognitively impaired. He required setup and cleanup help for eating and oral hygiene, supervision for toileting and personal hygiene, and partial to moderate assistance for bathing. He had an indwelling urinary catheter and was frequently incontinent of bowel. Review of the care plan dated 08/22/23 revealed Resident #61 was at risk for recurrent…
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 · D2024-06-25 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews, review of hospice notes, and review of the facility policy the facility failed to provide coordination of care between hospice and facility staff for Resident #61 related to pressure ulcer prevention. This affected one resident (#61) out of two residents reviewed for pressure ulcer prevention. The facility census was 60. Findings include: Review of the closed medical record revealed Resident #61 was admitted to the facility on [DATE] and expired on [DATE]. Diagnoses included but were not limited to dementia unspecified, severe, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, kidney disease, urine retention, colon cancer, malnutrition. Resident #61 was admitted to the hospice on [DATE]. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #61 was cognitively intact. The assessment noted he was at risk for pressure ulcer development and had no pressure ulcers. Review of Resident #61's physician orders 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 before2024-04-18 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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
Based on medical record review, review of a self-reported incident and interview, the facility failed to ensure medical records were accurate and complete for Residents #2 and #11. This affected two residents (#2 and #11) of three records reviewed for accuracy. The facility census was 70. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 07/10/20 with diagnoses including Alzheimer's disease, dementia, intermittent explosive disorder, and anxiety disorder. Further review of the medical record identified no documentation of any complaints of hip or knee pain and possible rotation of the leg for Resident #2. Review of the facility's investigation of Self-Reported Incident (SRI) #245125 revealed Resident #2's skin check identified complaints of pain to the left hip and knee and a slight internal rotation of the left leg. On 04/18/24 at 1:41 P.M., interview with Corporate Quality Assurance Nurse #107 verified Resident #2's skin check, obtained during the investigation of SRI #245125, revealed complaints of pain to his left hip and knee and a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide Resident #70 proper assistance with incontinence to prevent the resident from falling. This affected one Resident (#70). The facility census was 69. Findings include: Review of Resident #70's medical records revealed an admission date of 10/21/22 and a discharge date of 01/31/24. Diagnoses included corticobasal degeneration, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, gastrostomy, abnormal posture, contracture left hand, COVID-19, protein-calorie malnutrition, gastrostomy status, urogenital implants, neuromuscular dysfunction of bladder, pressure ulcer of sacral region, stage 4, diabetes mellitus due to underlying condition with food ulcer, adult failure to thrive, disorder of white blood cells, tachycardia, history of transient ischemic attack (TIA), and hypertension. Review of Resident #70's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had impaired cognition.…
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 · E2023-04-06 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interviews, staff interviews, review of activity calendars, and review of activity policy, the facility failed to ensure group activities were offered and provided per the resident's preferences and the activity calendar. This finding had the potential to affect 28 residents who participate in group activities including Residents #1, #2, #4, #5, #8, #12, #15, #16, #17, #22, #23, #25, #28, #30, #32, #34, #35, #36, #39, #42, #43, #48, #50, #56, #62, #121, #278, and #281. The facility census was 65. Findings include: On 04/05/23 2:03 P.M. during the Resident Council Meeting, Residents #16 and #56 stated they were unhappy that there were no activities on the weekends. Review of the activity calendar for January 2023 revealed weekend activities planned for 01/07/23 included daily visits, word search, and afternoon chats. 01/08/23 included daily visits, visits with a friend, and afternoon chats. 01/21/23 included daily visits, phone a friend, and afternoon chats. 01/22/23 included daily visits, word scramble, and afternoon chats. Review of the activity calendar 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.
Show the remaining 13 citations
- Potential for harm · Dcited before2023-04-06 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure resident assessments were completed accurately for Residents #2, #3, and #62. This affected three residents (#2, #3, #62) of 21 residents records reviewed. The facility census was 65. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 09/10/21. Diagnoses included major depressive disorder, bipolar disorder, and chronic pain. A new diagnosis of schizoaffective disorder was added 01/31/22. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 received an antidepressant for zero days out of the previous seven days. Review of the physician's orders identified an order for Fluoxetine HCl (a medication used to treat depression) 20 milligram (mg) tablet once daily. Review of the medication administration record (MAR) for January 2023 revealed Resident #2 received Fluoxetine HCl on 01/21/23, 01/22/23, 01/23/23, 01/24/23, 01/25/23, 01/26/23, and 01/27/23. 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.
- Potential for harm · D2023-04-06 · tag F0644 — isolatedCoordinate 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 record review and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) Assessment was completed following a new diagnosis of schizoaffective disorder. This affected one resident (#2) of one resident reviewed for PASARR. The facility census was 65. Findings include: Review of the medical record for Resident #2 revealed an admission date of 09/10/21. Diagnoses included major depressive disorder, bipolar disorder, and chronic pain. A new diagnosis of schizoaffective disorder was added 01/31/22. Review of the PASARR assessment dated [DATE] indicated Resident #2 did not have a serious mental illness or developmental disability. No other PASARR Assessments were identified for Resident #2. On 04/03/23 at 4:55 P.M., interview with Social Services Designee (SSD) #406 and SSD #470 verified Resident #2 had a new diagnosis of schizoaffective disorder on 01/31/22. They also confirmed no new PASARR Assessment was completed after the new diagnosis to determine if Resident #2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-06 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #20 was provided effective discharge planning. This finding affected one resident (#20) of one resident reviewed for discharge planning. The facility census was 65. Findings include: Review of Resident #20's medical record revealed she was admitted on [DATE] and discharged on 03/30/23 with diagnoses including mechanical loosening of the internal left knee prosthetic joint and presence of the left artificial knee. Review of Resident #20's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited intact cognition. Review of Resident #20's physician orders revealed an order dated 03/22/23 for the resident to return home with physical therapy (PT) and nursing after discharge home with Home Health Care (HHC) #1. Review of Resident #20's progress note dated 03/29/23 at 1:45 P.M. indicated the phone for HCC #1 would not ring and the resident approved HHC #2. Review of Resident #20's Discharge Instructions form dated 03/29/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-06 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, and staff interview, the facility failed to provide timely assistance with activities of daily living (ADL) for Resident #23. This affected one resident (#23) of two residents reviewed for ADL. The facility census was 65. Findings include: Review of the medical record for Resident #23 revealed an admission date of 04/04/18. Diagnoses included quadriplegia, bipolar disorder, personality disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had no cognitive impairment. Resident #23 required total dependence of two staff for transfers. Review of the care plan revised on 04/19/19 revealed Resident #23 preferred to go to bed at 9:00 P.M. and was totally dependent on two staff for transfers with a Hoyer (mechanical) lift. Review of the physician's orders for April 2023 identified orders for a Hoyer lift for all transfers. On 04/03/23 at 10:36 A.M., an interview with Resident #23 stated his care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-06 · 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 interview, record review, black box warning review, and facility policy review, the facility failed to ensure appropriate diagnosis for the use of psychotropic medications. This affected one resident (#21) of five residents reviewed for unnecessary medications. The census was 65 residents. Findings include: Review of the medical record for Resident #21 revealed an admission date of 03/01/19. Diagnoses included cerebral infarction, vascular dementia with agitation, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had severe cognitive impairment. The assessment also indicated Resident #21 had active diagnoses of a stroke, non-Alzheimer's dementia, and depression, and received an antipsychotic medication. Review of the physician's orders for April 2023 identified orders for Seroquel (an antipsychotic medication) 25 milligrams (mg) twice daily for restlessness, yelling out, and disruptive behavior related to vascular dementia. 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.
- Potential for harm · F2020-02-27 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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
Based on observation, interview and record review, the facility failed to ensure medications were dated when opened and disposed of in a timely manner. This had the potential to affect all 68 residents who reside in the facility. Findings include: During a tour of the medication room on the C unit with Registered Nurse #500 on 02/27/20 at 9:20 A.M., a vial of tuberculin (a medication used to test for the presence of tuberculosis) was found in the refrigerator. The vial was half full and was not dated. Additionally, a vial of influenza vaccine was found in the refrigerator. It was dated 10/02/19. A sign on the outside of the refrigerator indicated the influenza vaccine should be discarded 28 days after opening. RN #500 verified these findings. During a tour of the A unit medication room with RN #501 on 02/27/20 at 9:45 A.M., two vials of Vitamin K, a medication used to make blood clot faster, were found in a box of medications. RN #501 identified this as a starter box (a supply of medications to use until a full prescription of a medication arrives from the pharmacy). 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 · Ecited before2020-02-27 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for four (Residents #5, #18, #31, and #50) of 22 residents whose assessments were reviewed for accuracy. Findings include: 1. Review of a five day MDS assessment dated [DATE] indicated Resident #31 received anticoagulant medication three days. Review of Resident #31's January 2020 Medication Administration Record (MAR) did not reveal the use of anticoagulant medications. On 02/25/20 at 2:33 P.M., Registered Nurse (RN) #505 verified Resident #31's MDS dated [DATE] was coded incorrectly for anticoagulant use. Resident #31 had received aspirin which was not an anticoagulant. 2. Review of a five day MDS assessment dated [DATE] indicated Resident #18 received anticoagulants seven days. Review of Resident #18's December 2019 MAR did not reveal the use of anticoagulants. On 02/25/20 at 2:33 P.M., RN #505 verified Resident #18's MDS dated [DATE] was coded incorrectly for anticoagulant use. Aspirin…
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 before2020-02-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure falls were thoroughly assessed to determine appropriate interventions were in place to prevent future falls. This affected Resident #5, one of three residents reviewed for falls. The facility census was 68. Findings include: Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including muscle weakness, orthostatic hypotension (a sudden drop in blood pressure upon sitting or standing up ) and history of syncope (dizziness) and collapse. Review of her admission minimum data set assessment dated [DATE] revealed Resident #5 was severely cognitively impaired and required the extensive assistance of one staff member for her activities of daily living. Review of her fall risk assessment completed on 08/17/19 revealed she was at high risk for falls. Review of her fall care plan dated 08/17/19 revealed Resident #5 was at risk for falls due to confusion gait (walking) problems, history of falls, incontinence and use of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-02-27 · 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
Based on medical record review and interview, the facility failed to ensure medications were administered when medically necessary and according to physician's orders. This affected one (Resident #50) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #50's medical record revealed diagnoses including heart failure, autonomic neuropathy, and hypotension (low blood pressure). Resident #50 had a current physician's order for the administration of Midodrine, 15 milligrams three times a day. Midodrine is used to treat orthostatic hypotension (a sudden fall in blood pressure that occurs when a person assumes a standing position). The physician's order indicated the Midodrine was not to be administered if the systolic blood pressure (top number of the blood pressure) was greater than 130 or the diastolic (bottom number) blood pressure was greater than 70. Review of the February 2020 Medication Administration Record (MAR) revealed a blood pressure (BP) of 114/75 was recorded at bedtime on 02/06/20, 104/78 was recorded at bedtime on 02/16/20,…
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 before2020-02-27 · 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 antipsychotic medication ordered on an as needed basis had a limit to the time frame for use and failed to ensure attempts were made to implement non-pharmacological interventions prior to the use of as needed antipsychotic medication for insomnia. This affected one (Resident #50) of five residents reviewed for medication use. Findings include: Review of Resident #50's medical record revealed an initial admission date of 01/23/20. Resident #50 had diagnoses including obstructive sleep apnea and insomnia. Resident #50 had a physician's order for Seroquel (an antipsychotic medication) 50 milligrams (mg) at bedtime as needed, with no end date. Review of the January 2020 and February 2020 Medication Administration Records (MARs) revealed between 01/24/20 and 02/09/20, 16 doses of the as needed Seroquel were administered. Resident #50 was hospitalized [DATE] and returned 02/14/20 with the same order for Seroquel as needed for sleep with no…
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 before2020-02-27 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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
Based on record review and interview the facility failed to ensure accurate and complete documentation/physician orders regarding a fall and hospice services for Resident #5. This affected one of 21 residents reviewed for accurate and complete medical records. Findings include: Resident #5 was admitted to facility on 08/08/19 with a diagnosis of weakness, syncope (dizziness) and collapse, and muscle weakness. Resident #5 was on hospice services or end of life care upon admission to the facility. Review of the electronic medical record in Point Click Care (PCC), the electronic medical record system, revealed no physician order for hospice services for Resident #5. Review of a fall investigation revealed Resident #5 had a fall on 11/21/19. Review in Point Click Care (PCC), the electronic medical record, revealed no documentation regarding Resident #5's fall on 11/21/19. Interview on 02/26/20 at 5:00 P.M. with the corporate nurse, Registered Nurse, RN #505, confirmed the electronic medical record did not contain a physician order for hospice services for Resident #5. Interview 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.
- Potential for harm · D2020-02-27 · 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, interview, and record review, the facility failed to communicate and coordinate treatment of an eye infection with the workshop staff, failed to provide education regarding infection control procedures, and failed to address ongoing signs of an eye infection for Resident #41 and the facility failed to follow proper infection control procedures during catheter care for Resident #31. This affected one of two residents reviewed for infections and one of two residents reviewed for urinary catheters. Findings include: 1. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including athetoid cerebral palsy, borderline personality disorder, anxiety disorder, essential tremor, bipolar disorder, schizoaffective disorder, intellectual disabilities, conduct disorder (adolescent onset) and major recurrent severe depressive disorder with psychotic symptoms. Review of the service delivery guide from the workshop for intellectual disabilities 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.
- No harm found · C2020-02-27 · tag F0732 — widespreadPost nurse staffing information every day.
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 staffing was posted in a prominent area and contained all of the required information. This had the potential to affect all 68 residents who resided in the facility. Findings include: On entry to the facility on [DATE] at 9:00 A.M., a posting with all required staffing information, indicating how many staff were working was not observed in a visible area. An interview with the Administrator on 02/24/20 at 11:15 A.M. revealed the staffing posting was on a bulletin board in the main hall between the B hall and the C hall. The Administrator verified the facility had two entrances, one in front of the A hall and one in front of the C hall. The B hall was between the two other halls and was accessible from either door. He stated the only posting of staffing information was on the bulletin board. He verified any residents or family members who entered the building to go the A or C hall would have no real reason to enter the main hall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to WINDSOR HOUSE, INC. — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.5 | +0.5 vs chain |
| Health inspection | 4 of 5 | 3.2 | +0.8 vs chain |
| Staffing | 4 of 5 | 3.5 | +0.5 vs chain |
| Quality measures | 3 of 5 | 4.2 | -1.2 vs chain |
The other 10 homes this chain runs (chain average 3.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MASTERNICK, JOHN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 04/01/2014 |
| DALIMAN, JOHN | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 04/01/2014 |
| JAMES, KENNETH | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 04/01/2014 |
| FABIAN, PAUL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/14/2017 |
| ICLI, TOLGA | Individual | ADP OF THE SNF | — | since 09/14/2017 |
CMS files one row per role, so the 12 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.8M paid to related parties — landlords or management companies under common ownership — equal to about 34% 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 366460. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, 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.