Canton Christian Home
2550 Cleveland Avenue NW, Canton, OH 44709 · Non profit - Corporation · 57 certified beds · (330) 456-0004 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $9,113 in federal fines (most recent 2025-02-14)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 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 | 11.1% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 0.8% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.1% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.6% | 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 | 5.4% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 14.3% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 23.4% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 67.9% | 94.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 0.9% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.4% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.7% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 59.4% | 75.6% | 79.4% | 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.
53.7% 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 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% 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 | 53.7%CMS range 38.2–68.8 | 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 6.8–18.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 23.8% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 0.0% | 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 | 6.7%CMS range 3.4–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 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 57 beds and averages 52.9 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 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.27 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 3.24 hrs/resident/day on weekends vs 3.90 on weekdays — 17% thinner on weekends. RN hours go from 0.58 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · Gcited before2025-02-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of a facility investigation, review of a facility Self-Reported Incident, review of hospital records, interviews with staff, and review of facility policy, the facility failed to develop and implement a comprehensive and individualized fall prevention program to ensure Resident #45's safety and supervisory needs were addressed timely resulting in a fall with major injury. In addition, the facility failed to ensure appropriate interventions were implemented to prevent additional falls/injury. Actual harm occurred on 01/17/25 when Resident #45, who required a mechanical lift for transfers, was at high risk for falls, and had moderately impaired cognition, was hospitalized after sustaining right and left tibial fractures following an unwitnessed fall. Prior to the unwitnessed fall, a nursing assistant observed the resident yelling for help with her legs hanging out of bed and walked past her room without responding to the resident's calls for help. This affected 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.
- Actual harm · Gcited before2024-05-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, observation, review of a facility investigation, and facility policy review, the facility failed to ensure residents were properly transferred by mechanical lift. This affected two residents (#22 and #44) of three residents reviewed for transfers. The facility census was 53. Actual Harm occurred on 05/05/24 when two State Tested Nursing Assistants (STNA's) were transferring Resident #22, who had severely impaired cognition and was dependent on staff for transfers, via mechanical lift to her wheelchair and failed to operate the mechanical lift properly, resulting in Resident #22 falling and sustaining a spiral femur fracture requiring surgery and hospitalization. The resident was assessed to exhibit severe pain with leg movement following the incident and signs/symptoms of pain/distress throughout the morning of 05/06/24 before being transferred to the hospital. Findings included: 1. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses…
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 before2025-12-11 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, self-reported incident (SRI) review, review of the police incident report, personnel file review, interviews facility policy review, the facility failed to ensure Resident #43 was treated with dignity while care was being provided. This affected one (Resident #43) of one resident reviewed for dignity. The facility census was 49.Findings include:Review of the medical record for Resident #43 revealed an admission date of 07/16/25. Diagnoses included hypo-osmolality and hyponatremia, adult failure to thrive, hypertensive chronic kidney disease and personal history of urinary tract infections.Review of the 10/01/25 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #43 revealed intact cognition. The resident required maximum assistance from staff for transfers and was dependent upon staff for toileting.Review of Resident #43's care plan with a revision date of 10/09/25 revealed an activity of daily living (ADL) self-care performance and mobility deficits related 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.
- Potential for harm · D2025-12-11 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, interview and facility policy review, the facility failed to ensure a baseline care plan was completed as required for Resident #52. This affected one (Resident# 52) of nine residents reviewed for baseline care plans. The facility census was 49.Findings include: Review of the medical record for Resident #52 revealed an admission date of 10/01/25 and a discharge date of 10/17/25. Diagnoses included but were not limited to sepsis, morbid obesity, stage IV chronic kidney disease and liver cell carcinoma.Review of the 10/07/25 admission Minimum Data Set (MDS) 3.0 assessment for Resident #52 revealed intact cognition. Resident #52 was noted to require moderate assistance to being fully dependent upon staff for activities of daily living (ADL).Interview on 12/10/25 at 3:00 P.M. with the Director of Nursing (DON) confirmed she was unable to provide evidence of a baseline care plan for Resident #52. Review of the 11/22/16 facility policy titled: Resident Directed Care Planning Policy and Procedure revealed the interdisciplinary team (IDT) shall develop 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 · D2025-12-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of the medical record, interviews and facility policy review, the facility failed to ensure bathing was provided and documented as requested and required for Resident #29. This affected one (Resident #29) of one resident reviewed for bathing. The facility census was 49. Findings include:Review of the medical record for Resident #29 revealed an admission on [DATE]. Diagnoses included but were not limited to Parkinson's disease, obesity, dementia and generalized anxiety disorder.Review of the 11/04/25 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #29 revealed intact cognition. Resident #29 was noted to require moderate staff assistance with bathing and shower transfer.Review of the 11/15/25 bathing assessment for Resident #29 revealed she preferred a tub bath twice a week on day shift.Review of the care plan for Resident #29 revealed it was last reviewed on 11/17/25. Resident #29 was noted to have activities of daily living (ADL) performance and mobility deficits related 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.
- Potential for harm · Dcited before2025-12-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure the treatment to Resident #8's right heel was completed as ordered. This affected one (Resident #8) out of one resident reviewed for wound care. The facility census was 49.Findings include:Review of the medical record revealed Resident #8 was admitted on [DATE] with diagnoses that included but not limited to chronic pain, protein calorie malnutrition, and anxiety. A plan of care dated 08/29/25 revealed Resident #8 had a pressure ulcer to right heel. Interventions included but not limited to treatments to be administered as ordered and to monitor for effectiveness. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated cognitive impairment. The MDS also revealed Resident #8 had an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · 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 record review, review of self-reported incident (SRI) tracking #264837, interviews, observations and facility policy review, the facility failed to ensure Resident #61 was not outside the facility without adequate supervision. This affected one (Resident #61) out of one resident reviewed for accidents. The facility census was 49. Findings include: Review of the medical record revealed Resident #61 was admitted on [DATE] and discharged on 09/16/25 with diagnoses that included chronic atrial fibrillation, dementia, major depressive disorder, generalized anxiety, insomnia, restlessness and agitation, and chronic pain.A care plan dated 01/01/23 revealed Resident #61 was at risk for injury related to dementia. Resident #61 wanders looking for wife, has impaired safety awareness, and short attention span. Interventions included wander management system to wrist or leg and checked every shift, attempt to redirect when focused on leaving the facility unassisted or without supervision, if the resident attempts…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-11 · 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 record review, observation, interview and facility policy review, the facility failed to ensure staff followed standard infection control precautions during medication administration. This affected one (Resident #16) of four residents observed during medication administration. The facility also failed to maintain proper infection control practices while providing wound care for Resident #8. This affected one (Resident #8) of one resident observed for wound care. The facility census was 49.Findings include:1. Review of the medical record for Resident #16 revealed an admission date of 10/16/25 with diagnoses including dementia, chronic kidney disease and diabetes mellitus. Review of the physician's orders for Resident #16 for December 2026 revealed she had an orders for Buspirone 10 milligrams (mg) three times a day for anxiety dated 10/16/25, Gabapentin 300 mg twice daily for nerve pain dated 10/16/25, Memantine 10 mg twice daily for dementia dated 10/16/25, Senna Plus 8.6-50 mg two tablets twice daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-03-23 · tag F0885 — failed to notify residents/families about COVID-19 — widespreadReport COVID19 data to residents and families.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of list of COVID positive staff, review of robo call report, interview, and policy review, the facility failed to ensure residents, their representatives, and families were notified timely after confirmation of staff testing positive for COVID-19. This had the potential to affect all 53 residents in the facility. Findings included: Review of list of COVID positive staff undated revealed State Tested Nurse Aide (STNA) #319 tested positive for COVID-19 on 03/13/23 and STNA #337 on 03/16/23. Review of robo call report dated 03/20/23 revealed residents, their representatives, and families were not notified until 03/20/23 at 10:36 A.M., of the positive staff member from 03/15/23 and 03/16/23. The message reported the facility had two staff member test positive for COVID in the last week. Review on facilities policy titled Confirmed COVID-19 cases Notification revised 09/2022 revealed all families, residents, and staff would be notified by utilizing the robo-calling, skype, 1:11 phone calls, letters, memos, and direct communication within 72 hours of the known infections.…
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 before2023-03-23 · 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 self reported incident review, medical record review and staff interview the facility failed to ensure residents were treated with respect and dignity by staff members. This affected one (Resident #7) of three residents reviewed for respect and dignity. The facility census was 53. Findings include: Review of the facility self reported incident (SRI) #213229 revealed on 10/21/21 State Tested Nurse Aide (STNA) #359 was witnessed by staff members speaking to Resident #7 forcefully and pointing her finger at the resident telling Resident #7 to not bother her for assistance when she is with a different resident. Further review of the facility SRI investigation revealed statements obtained by staff witnesses STNA #327, STNA #361 and STNA #322. All STNAs indicated they witnessed STNA #359 talking disrespectfully to Resident #7 when Resident #7 was asking for assistance. Staff indicated STNA #359 pointed her finger and told Resident to not bother her when she is working with another resident. A statement obtained from Resident #7 indicated she was waiting for ambulation assistance…
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 · D2023-03-23 · 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, review of the facility self-reported incidents, staff interview, and review of the facility policy on abuse, the facility failed to ensure the results of all abuse allegation investigations were reported in a timely manner. This affected three (#3, #15, and #25) of seven residents reviewed for abuse. The census was 53. Findings include: 1. Review of the open medical record for Resident #25 revealed an admission date of 10/27/20. Diagnoses included cerebrovascular disease, anxiety disorder, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had severely impaired cognition. Review of the progress note dated 02/11/22 at 6:34 A.M. revealed Resident #25 was brought to the nurse's station with a report that she had left the building. Review of the facility self-reported incident (SRI) #217752 revealed it was created on 02/10/22 and completed on 03/31/22. On 03/23/23 at 10:25 A.M., interview with the Director of Nursing (DON)…
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 · D2023-03-23 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond 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 record review, review of the facility self-reported incidents, staff interview, and review of the facility policy on abuse, the facility failed to conduct a thorough investigation for an allegation of abuse. This affected two (#3 and #13) of seven residents reviewed for abuse. The census was 53. Findings include: 1. Review of the open medical record for Resident #3 revealed an admission date of 11/13/20. Diagnoses included vascular dementia with agitation, anxiety disorder, history of falling, history of transient ischemic attack, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 01/18/23, revealed Resident #3 had no cognitive impairment and required extensive assistance of one staff for activities of daily living (ADL). Review of the facility self-reported incident (SRI) #203299, dated 03/09/21, revealed Resident #3 stated she was thrown into bed and this resulted in a skin tear to her left forearm. There were no named witnesses, no named alleged perpetrators,…
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 · D2023-03-23 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 all required information was sent to the receiving provider upon Resident #50's transfer to the hospital. This affected one resident (Resident #50) out of one resident reviewed for hospitalization. Findings Include: Resident #50 admitted to facility on 02/03/23 with diagnoses of cerebral vascular accident, anxiety disorder, pneumonia, history of fall with right hip fracture, and cognitive deficits. Review of the Base Line Care Plan dated 02/04/23, revealed Resident #50 required assist of one staff member for activities of daily living (ADL). Resident #50 Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven, indicating moderate cognitive impairment. Review of progress note dated 02/15/23 at 5:50 PM, revealed Resident #50 slid out of the recliner on to the floor. Progress note dated 02/15/23 at 6:17 PM revealed Licensed Practical Nurse (LPN) #334 assessed Resident #50…
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 · D2023-03-23 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify Resident #50's resident representative in writing of the resident's transfer and discharge. This affected one resident (Resident #50) out of one resident reviewed for hospitalization. Findings Include: Resident #50 admitted to facility on 02/03/23 with diagnoses of cerebral vascular accident, anxiety disorder, pneumonia, history of fall with right hip fracture, and cognitive deficits. Review of the Base Line Care Plan dated 02/04/23, revealed Resident #50 required assist of one staff member for activities of daily living (ADL). Resident #50 Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven, indicating moderate cognitive impairment. Review of progress note dated 02/15/23 at 5:50 PM, revealed Resident #50 slid out of the recliner on to the floor. Progress note dated 02/15/23 at 6:17 PM revealed Licensed Practical Nurse (LPN) #334 assessed Resident #50 for injury;…
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 · D2023-03-23 · tag F0635 — isolatedProvide doctor's orders for the resident's immediate care at the time the resident was admitted.
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 record review, review of hospital records, and interviews the facility failed to ensure a newly admitted resident had routine care and dietary orders to provide immediate care. This affected one (Resident #203) of three closed records reviewed. Findings included: Closed medical record for Resident #203 revealed the resident was admitted on [DATE] with diagnoses including syncope and collapse, chronic kidney disease, nonrheumatic mitral valve, absence of kidney, Barrett's esophagus, chest pain, atrial fibrillation, depression, pain, and hypotension. Review of Resident #203's nursing note dated 09/09/22 at 6:43 P.M., revealed the resident was admitted to the facility from the a local hospital and left against medical advice (AMA) on 09/10/22 at 11:22 A.M. Review of Resident #203's physician orders dated 09/09/23 to 09/10/23 revealed there was only orders for medication and code status. There was no evidence of orders for diet or routine care. Review of Resident #203's nursing note dated 09/10/22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-23 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, review of hospital records, and interviews, the facility failed to ensure a newly admitted resident received quality standard care. This affected one (Resident #203) of three closed records reviewed. Findings included: Closed medical record for Resident #203 revealed the resident was admitted on [DATE] with diagnoses including syncope and collapse, chronic kidney disease, nonrheumatic mitral valve, absence of kidney, Barrett's esophagus, chest pain, atrial fibrillation, depression, pain, and hypotension. Review of Resident #203's nursing note dated 09/09/22 at 6:43 P.M., revealed the resident was admitted to the facility from the a local hospital and left against medical advice (AMA) on 09/10/22 at 11:22 A.M. Review of Resident #203's physician orders dated 09/09/23 to 09/10/23 revealed there was only orders for medication and code status. There was no evidence of orders for diet or routine care. Review of Resident #203's nursing note dated 09/10/22 created at 2:56 P.M., by…
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 before2023-03-23 · 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 and staff interview, the facility failed to ensure residents with pressure ulcer wounds had wound assessments completed at least every seven days. This affected one (Resident #204) of two residents reviewed for wounds. Findings include: Review of Resident #204's medical record revealed an admission date of [DATE] with a readmission date of [DATE]. admission diagnoses included pressure ulcer to the heel, Alzheimer's disease with dementia and chronic obstructive pulmonary disease. Further review of the medical record revealed upon readmission to the facility on [DATE], Resident #204 was identified with a pressure ulcer wound to the right heel. Initial pressure ulcer wound assessment was completed on [DATE] which identified the wound as a stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) measuring 4.0 centimeters (cm) by 5.0 cm and a depth of less than 0.1 cm. Further review of the wound assessments…
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 · D2023-03-23 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received restorative therapy per plan of care. This affected one (Resident #12) of one reviewed for limited range of motion. Findings included: Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, senile ectropion of eyelid, ganglion, pain left and right leg, anorexia, dysphagia, constipation, hyponatremia, abdominal pain, neuropathy, abnormal weight loss, neoplasm of skin of scalp and neck, pain in toes, edema, gout, restless leg syndrome, polyneuropathy, heart failure, rheumatoid arthritis, osteoarthritis of left wrist, presbyopia, pain, dementia, chronic kidney disease, Alzheimer's, gastro-esophageal reflux disease, hyperlipidemia, joint pain unspecified, vitiligo, urge incontinence, and effusion of ankle and foot. Review of Resident #12's range of motion plan of care revealed the resident was at risk for impaired mobility due to activity of daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-23 · 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 record review and interview the facility failed to complete a comprehensive fall investigation to include root cause and ensure the safety of the resident after a fall with injury. This affected one resident (Resident #50) out of two residents reviewed for falls. Findings Include: Record review on 03/20/23 revealed Resident #50 admitted to facility on 02/03/23 with diagnoses of cerebral vascular accident, anxiety disorder, pneumonia, history of fall with right hip fracture, COVID 19 and cognitive deficits. Resident #50 Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven, indicating moderate cognitive impairment. Review of the Base Line Care Plan dated 02/04/23, revealed Resident #50 required assist of one staff member for Activities of Daily Living (ADL) including transfers and toileting. Review of Resident #50's Fall Care Plan dated 02/06/23 revealed interventions to prevent falls included call light with in reach,…
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 · D2023-03-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review, the facility failed to ensure Resident #11's pharmacy review was acted upon timely, as needed psychotropic medication had stop dates, and resident received appropriate dose of anti-anxiety medication. This affected one (Resident #11) of five reviewed for medications. Findings included: Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including dementia with mood disorder, anxiety, depression, restlessness, insomnia, impulsiveness, and Alzheimer's. 1. Review of Resident #11's pharmacy recommendation dated 03/08/23 recommended to discontinue Remeron 7.5 milligrams (mg). The physician agreed to discontinue the Remeron on 03/15/23. Review of Resident #11's physiatrist note dated 03/15/23 revealed to discontinue Remeron. Review of Resident #11's orders and Medication Administration Records dated 03/2023 revealed no evidence the Remeron 7.5 mg had been discontinued. Interview on 03/22/23 at 1:23 P.M., with 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 · D2023-03-23 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident received laboratory testing per orders. This affected one (Resident #45) of five reviewed for medication review. Findings included: Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including Parkinson's with orthostatic hypotension, edema, hypertension, atrial fibrillation, aortic aneurysm, and anemia. Review of Resident #45's orders dated 02/2023 revealed to check a Complete Blood Count (CBC) and Complete Metabolic Panel (CMP) every six months for hypertension and anemia. Review of Resident #45's laboratory results revealed on 02/21/23 no evidence a CMP was completed, however there was basic metabolic panel collected (BMP) along with a CBC. Interview on 03/22/23 at 3:42 P.M., and 02/23/23 at 9:12 A.M., with the Director of Nursing (DON) confirmed on 02/21/23 a CMP should have been collected not a BMP. There was no order to collect a BMP. The DON reported she had spoken to the attending…
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 · D2023-03-23 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, email review, interviews, and policy review, the facility failed to ensure a resident with Medicaid received timely dental services per therapy/physician orders. This affected one (Resident #12) of one reviewed for dental services. Findings included: Resident #12 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, senile ectropion of eyelid, ganglion, pain left and right leg, anorexia, dysphagia, constipation, hyponatremia, abdominal pain, neuropathy, abnormal weight loss, neoplasm of skin of scalp and neck, pain in toes, edema, gout, restless leg syndrome, polyneuropathy, heart failure, rheumatoid arthritis, osteoarthritis of left wrist, presbyopia, pain, dementia, chronic kidney disease, Alzheimer's, gastro-esophageal reflux disease, hyperlipidemia, joint pain unspecified, vitiligo, urge incontinence, effusion of ankle and foot. Resident #12 received Medicaid. Review of Resident #12's undated dental consent revealed 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 · D2023-03-23 · tag F0800 — isolatedProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary 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 closed record review and interviews, the facility failed to ensure a newly admitted resident had diet orders and received their breakfast tray timely. This affected one (Resident #203) of three closed records reviewed. Findings included: Closed medical record for Resident #203 revealed the resident was admitted on [DATE] with diagnoses including syncope and collapse, chronic kidney disease, nonrheumatic mitral valve, absence of kidney, Barrett's esophagus, chest pain, atrial fibrillation, depression, pain, and hypotension. Review of Resident #203's physician orders dated 09/09/23 to 09/10/23 revealed no evidence of diet orders. Review of Resident #203's nursing note dated 09/10/22 created at 2:56 P.M., by Licensed Practical Nurse (LPN) #300 revealed the LPN entered the resident's room at 9:47 A.M. and observed there was no breakfast tray on the tray table. The LPN inquired if she had breakfast this morning. The resident stated she didn't have breakfast yet. The LPN proceeded to let the resident know she…
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 before2023-03-23 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, facility policy review and staff interview, the facility failed to ensure antibiotic assessments were completed to determine appropriate use and indication for antibiotic medications. The affected three (Residents #8, #16 and #23) of eight residents reviewed for antibiotic use. The facility census was 53. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 09/13/19 with diagnoses that included diabetes mellitus, dementia, chronic kidney disease and peripheral vascular disease. Further review of Resident #8's medical record including physician's medication orders revealed on 01/25/22 Resident #8 was prescribed the use of Levaquin (antibiotic) 500 milligrams (mg) daily for seven days for pneumonia. Further review of Resident #8's medical record found no evidence of an antibiotic assessment completed prior to antibiotic initiation to determine if antibiotic use was appropriate and indicated. Review of the facility policy titled Infection Control: Antibiotic Stewardship Policy with a revision date of 08/01/18…
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 before2020-02-20 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, policy review and staff interview, the facility failed to ensure antibiotics were used with appropriate indications for use and facility policy indicated criteria used to determine appropriate antibiotic use. This affected two (Resident #12 and #45) of six residents reviewed for antibiotic use. The facility census was 69. Findings include: 1. Review of Resident #12's medical record revealed an admission date of 08/30/2019 with diagnosis that included Alzheimer's disease with dementia. Further review of the medical record revealed on 02/06/2020, Resident #12 was initiated on Doxycycline (antibiotic) 100 milligram (mg) twice daily for seven days for possible cellulitis (infection) of the left lower extremity. Further review of the medical record found no evidence of McGeer's Surveillance Criteria was completed to determine if antibiotic use was appropriate for use. 2. Review of Resident #45's medical record revealed an admission date of 10/22/2019 with diagnosis that included end stage renal disease with dependence on hemodialysis. Further review of 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.
“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
$9,113 in federal fines across 1 penalty.
- $9,113 — penalty dated 2025-02-14
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| NICKOSON, ROBERT | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; TRUSTEE OF THE SNF; ADP OF THE SNF | since 05/20/2015 |
| STACKHOUSE, JANINE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/28/2023 |
| YODER, HEATHER | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | since 02/06/2018 |
| FRANZ, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/06/2018 |
CMS files one row per role, so the 11 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
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 366300. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, 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.