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Otterbein Springboro

9320 Avalon Circle, Centerville, OH 45458 · Non profit - Corporation · 60 certified beds · (937) 885-5426 Medicare & Medicaid certified

Call the home — (937) 885-5426 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0569)Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0569)
  • 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
  • its facility-reported quality-measure score sits well above its independent inspection score

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

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
78 Remick Blvd · (937) 886-9017 · Call to confirm hours
Pharmacy
710 N Main St · (937) 748-1135 · Call to confirm hours
Grocery
740 N Main St · (937) 748-6800 · Call to confirm hours
Park
525 W Lytle-Five Points Rd · (937) 748-9721 · Typically dawn to dusk
Place of worship
650 W Lytle 5 Points Rd · (937) 353-7713

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.7%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight4.3%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms22.7%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.7%3.2%3.3%better
Long-stay residents whose ability to walk worsened4.9%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication25.7%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine98.0%94.5%95.3%typical
Long-stay residents with pressure ulcers0.8%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control30.7%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.2%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%75.6%79.4%better
Short-stay residents rehospitalized after admission18.9%24.9%22.6%better
Short-stay residents with an outpatient ER visit13.4%12.9%12.0%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.

58.3% 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 138 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.3%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
56.2%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 56.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 48 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.37 therapist hours per resident per day in 2026Q1 — more than 64% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF58.3%CMS range 47.8–68.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 8.0–13.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge56.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge60.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge43.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting93.6%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.2%CMS range 3.3–9.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.991.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.75
RN hours/ resident / day
0.67
LPN hours/ resident / day
3.02
Aide hours/ resident / day
4.44
Total nurse hours/ resident / day
0.48
RN hoursweekends
42.9%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 57.3 residents a day — about 96% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. 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 4.44 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.02 is at or above 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 4.20 hrs/resident/day on weekends vs 4.54 on weekdays — 8% thinner on weekends. RN hours go from 0.86 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% 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

9
deficiencies at the latest standard inspection (2026-04-30)
2
at the previous standard inspection (2022-10-18)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · E2026-04-30 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and policy review, the facility failed to ensure medication carts were locked. This affected one of four medication carts observed and had the potential to affect 11 Residents (#5, #7, #14, #15, #18, #33, #34, #52, #54, #55, and #57) whose medications were stored in the cart. The facility census was 57.Findings include: Observation of the 300 cottage medication cart on 04/30/26 at 8:10 A.M. revealed it was unlocked and a nurse was not visible near the unsecured medication cart. Interview and observation on 04/30/26 at 8:12 A.M., the Administrator verified the 300 cottage medication cart was unlocked and a nurse was not present in the cottage. The Administrator verified Residents' (#5, #7, #14, #15, #18, #33, #34, #52, #54, #55, #57) medications were stored in the cart. Review of the facility policy titled Medication Storage in the Facility dated May 2022 revealed medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-30 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview and review of the week at a glance menu, the facility failed to ensure the menu portion sizes were followed. This affected twelve (Resident #09, #10, #16, #19, #20, #32, #35, #37, #39, #40, #41 and #51) out of 57 residents that resided in the facility. The facility census was 57. Findings Include:Review of the facility's a week at a glance menu for house 9349 dated 04/27/26 revealed residents on a regular and bite sized diets were to receive five ounces of grilled chicken, four ounces of broccoli, a half of a cup of rice pilaf and one breadstick for lunch on 04/27/26.Observation of the kitchen in house 9349 on 04/27/26 at 12:36 P.M. revealed Certified Nursing Assistant (CNA) #166 was serving residents on regular diets two scoops of broccoli using an unlabeled spoon, a scoop of rice using an unlabeled spoon, a piece of chicken that she cut in half and a breadstick. The CNA #166 was serving residents on bite size diets two scoops of broccoli using an unlabeled spoon, a scoop of rice using an unlabeled spoon, a piece of chicken that she cut in half…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-30 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, facility documentation, review of manufacturers recommendations, and policy review, the facility failed to serve food in a manner that protected against cross-contamination. This affected 21 (Residents #5, #7, #14, #15, #18, #27, #33, #34, #52, #54, #55, #56, #57, #64, #65, #66, #68, #69, #70, #71, and #72) residents. Additionally, the facility failed to maintain appropriate dishwashing equipment. This had the potential to affect 12 (Residents #2, #6, #8, #22, #23, #28, #30, #31, #46, #48, #49, and #50) residents in unit 9335. The facility census was 57.Findings include: 1. Observation on 04/27/26 from 12:13 P.M. to 12:23 P.M. revealed Certified Nursing Assistant (CNA) #124 donned blue disposable gloves and prepared food plates for ten (#27, #56, #64, #65, #66, #68, #69, #70, #71, and #72) residents on the rehab unit including one sloppy joe sandwich, one scoop of macaroni and cheese, one prepared garden salad, and one prepared cup of canned fruit. CNA #124 prepared each sandwich by reaching into a bag with her gloved hands, retrieving 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-30 · tag F0569 — isolated
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    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, staff interview, review of the resident funds accounting record and policy review, the facility failed to ensure resident funds were conveyed within 30 days of discharge from the facility. This affected one (Resident #73) out of five residents reviewed for resident funds. The facility census was 57.Findings Included:Review of Resident #73's medical record revealed Resident #73 admitted to the facility on [DATE]. Diagnoses included cerebral infarction, adult failure to thrive, osteoarthritis, hypertension, chronic kidney disease, dementia moderate with agitation, and anxiety disorder. Resident #73 discharged from the facility on 10/13/25. Review of Resident #73's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #73's resident funds authorization dated 10/03/22 revealed Resident #73's Power of Attorney (POA) authorized Resident #73 to have a resident funds account at the facility. Review of Resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-30 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to ensure a resident had an activities care plan. This affected one (Resident #23) out of 20 residents sampled. The facility census was 57.Findings Included: Review of Resident #23's medical record review revealed Resident #23 admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease with late onset, paroxysmal atrial fibrillation, incisional hernia with obstruction without gangrene, hypertension, pure hypercholesterolemia, sleep apnea, atherosclerotic heart disease of native coronary artery without angina pectoris, generalized anxiety disorder, major depressive disorder, dementia in other diseases classified elsewhere unspecified severity with other behavioral disturbance, acute kidney failure, restlessness and agitation, other vitamin B12 deficiency, iron deficiency anemia, anxiety disorder and major depressive disorder. Review of Resident #23's annual Minimum Data Set (MDS) assessment dated [DATE] revealed…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-30 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure care plans reflected resident's needs regarding tube feeding. This affected one (Resident #3) out of four residents reviewed for care planning. The facility census was 57.Findings Included:Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, neurocognitive disorder with Lewy Bodies and dysphagia oropharyngeal phase. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #3 has severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 00. Resident #3 was dependent for activities of daily living (ADLs) and required a Hoyer lift for transfers.Review of Resident #3's physician's orders and medication administration record revealed the resident was receiving Jevity 1.5 at 30 milliliters (ml) per hour via gastrostomy tube.Review of the care plan dated 02/07/26 revealed Resident #3…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-30 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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, observation, staff interview, review of manufacturer's instructions, and policy review, the facility failed to ensure insulin pen administration devices were primed. This affected one (Resident #37) out of three residents observed during medication administration. The facility census was 57.Findings include:Review of Resident #37's medical record revealed an admission of 05/14/25. Diagnoses included type two diabetes mellitus, anxiety disorder, chronic kidney disease, and dementia.Review of an annual minimum data set (MDS) dated [DATE] revealed Resident #37 had moderately impaired cognition and received insulin injections.Review of physician orders revealed an order dated 09/26/25 for Admelog SoloStar (a rapid acting insulin) 100 units per milliliter (unit/ml) solution pen-injector. Inject six units subcutaneously before meals related to type two diabetes mellitus with hyperglycemia. Observation on 04/29/26 at 7:31 A.M. revealed Registered Nurse (RN) #312 prepared Resident #37's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-30 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interviews, and policy review, the facility failed to provide Enhance Barrier Precautions (EBP) for residents with wounds. This affected two (Residents #67 and #68) of four residents observed for infection control. In addition, the facility failed to ensure appropriate hand sanitization during wound treatments. This affected one (Resident #51) of two residents sampled for wound care. The facility census was 57.Findings include: 1. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE]. Diagnoses included unspecified fracture of the lumbar vertebra, rheumatoid arthritis, and obstructive sleep apnea.admission Minimum Data Set (MDS) assessment not yet completed. Review of the care plan dated 04/24/26 revealed Resident #67 had impaired skin integrity related to surgical wound to back. Interventions included applying back brace for comfort, administering treatments as ordered, completing weekly skin checks, providing…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-30 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of the Centers for Disease Control and Prevention (CDC) recommendations, the facility failed to ensure a pneumococcal vaccine was offered to a resident. This affected one (Resident #43) out of five residents reviewed for vaccinations. The facility census was 57.Findings Included:Review of the medical record revealed Resident #43 admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, hypertension, dysphagia, hyperlipidemia, spinal stenosis, heart failure, constipation, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, major depressive disorder, epilepsy, generalized anxiety disorder and insomnia.Review of Resident #43's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required set up assistance with eating. Resident #43 required supervision with…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and review of employee orientation documents, the facility failed to ensure a safe environment in the kitchen. This had the potential to affect four facility-identified cognitively impaired and independently-mobile (Residents #4, #6, #18, #22) of 12 residents residents residing in the house. The facility census was 58 residents. Findings include: Observation on 09/22/25 at 9:12 A.M revealed there was pot of eggs cooking in a boiling water on top of gas stove in the house kitchen. The gates to prevent entry to the kitchen were opened, and the kitchen was unattended by staff. Interview on 09/22/25 at 9:13 A.M with the Administrator confirmed there was an unsupervised gas stove on with a pot of eggs cooking with the kitchen gates opened. The Administrator also confirmed that the stove should never be left unattended while on and that the kitchen gates are supposed to be closed when the kitchen is left unattended or when the stove is in use.Interview on 09/22/25 at 9:55 A.M with Certified Nursing Assistant (CNA) #105 confirmed staff never leave 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Fcited before2022-10-18 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and review of facility policy, the facility failed to ensure foods were stored properly to potentially prevent spoilage. This had the potential to affect 24 (Residents #19, #5, #46, #32, #11, #16, #48, #30, #54, #50, #25, #38, #40, #23, #37, #6, #49, #33, #12, #47, #21, #9, #35, and #155) who resided in House #49 and House #35. The facility's census was 57. Findings include: Observation on 10/11/22 at 10:32 A.M. in House #49's kitchen revealed following sanitation violations: 1. Open container of juice was unlabeled 2. Pitcher of dark liquid was unlabeled and undated 3. Opened package of cream cheese with no date 4. Container of bacon and turkey with no open date Interview on 10/11/22 at 10:32 A.M. with State Tested Nurse Aide (STNA) #14 working in House #49, verified food should be labeled and dated. Observation on 10/11/22 at 10:45 A.M. in House #35's kitchen revealed following sanitation violations: 1. Opened bologna package undated 2. Container applesauce undated 3. Opened juice bottle not dated Interview on 10/1122 at 10:45 A.M. with State…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan to reflect the resident's risk for Urinary Tract Infections (UTIs). This affected one (Resident #18) of three residents reviewed for comprehensive care plans. The facility census was 57. Findings include: Review of the medical record for Resident #18 revealed she was admitted to the facility on [DATE]. Diagnoses included heart failure, type II diabetes, morbid obesity, paroxysmal atrial fibrillation, acute respiratory failure, specified disorders of kidney and ureter, depression, anxiety, and rheumatoid arthritis. Review of the Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact. Resident #18 required extensive two person assist for all activities of daily living. The MDS also revealed Resident #18 was frequently incontinent of urine and bowel. Review of the hospital discharge documents dated 07/19/22 revealed Resident #18 was admitted to the hospital for sepsis due…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-11-14 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of personnel files, and staff interviews, the facility failed to ensure State Tested Nurse Aides (STNAs) received 12 hours of yearly in services. This affected five STNAS (#15, #35, #65, #69 and #76) of six STNAs reviewed for yearly in services. This had the potential to affect all residents residing in the facility. The facility census was 42. Findings include: 1. Review of STNA #15's personnel file revealed a hire date of 07/11/12. Further review of the personnel file revealed STNA #15 only received 4.25 hours of in services from 07/11/18 to 07/11/19. 2. Review of STNA #35's personnel file revealed a hire date of 12/06/17. Further review of the personnel file revealed STNA #35 only received one hour of in services from 12/06/17 to 12/06/18. 3. Review of STNA #66's personnel file revealed a hire date of 08/20/15. Further review of the personnel file revealed STNA #66 received no in services from 08/05/18 to 08/05/19. 4. Review of STNA #69's personnel file revealed a hire date of 04/26/11. Further review of the personnel file revealed STNA #69 received no in services…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-11-14 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement 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 and interview, the facility failed to ensure as needed psychotropic medication orders were limited to 14 days or that a rationale and duration of the as needed (PRN) psychotropic medication was indicated in the medical record. This affected four Residents (#6, #16, #18 and #27) of five residents reviewed for unnecessary medications. The facility census was 42. Findings include: 1. Record review revealed Resident #18 was admitted to the facility on [DATE] with the following diagnoses; essential hypertension, major depressive disorder, macular degeneration, psychosis, vascular dementia, and dysphagia. Review of Resident #18's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, dressing, eating. Resident #18 also required total dependence with transfers, toileting and personal hygiene. Review of Resident #18's physician orders dated 02/19/19 revealed the resident was prescribed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-11-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and facility policy review, the facility failed to ensure food items were maintained, distributed and stored in a manner to prevent and protect food against contamination and spoilage. This had to potential to affect 35 Resident's (#3, #4, #5, #6, #8, #9, #11, #12, #13, #15, #16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #31, #32, #33, #34, #35, #36, #37, #39, #40, #41, #42, #43 and #194) who resided in the affected houses (9335, 9336, 9349, and 9350). The facility census was 42. Findings include: 1. Observation of house 9336 on 11/12/19 at 9:35 A.M. revealed there was one quart of ice cream that was opened, undated and unlabeled in the freezer in the kitchen. Interview with State Tested Nurse Aide (STNA) #81 at the time of the observation verified there was one quart of ice cream that was opened, undated and unlabeled in the freezer in the kitchen of house 9336. 2. Observation of house 9350 on 11/12/19 at 9:48 A.M. revealed the following: there was one expired bag of hot dog buns dated 10/24/19, one expired loaf of honey wheat bread…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-14 · tag F0646 — isolated
    Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews, the facility failed to notify the state mental health authority with a significant change pre-admission screening and resident review (PASARR) for a resident with a significant change in their physical health condition. This affected one (Resident #5) of one resident reviewed for significant change PASARR. The facility census was 42. Findings include: Record review revealed Resident #5 was admitted to the facility on [DATE] with the following diagnoses; congestive heart failure, hypertension, anxiety disorder, bipolar disorder, unspecified schizophrenia, borderline personality disorder, hyperlipidemia and neuropathy. On 02/08/19 the resident was admitted to hospice services for congestive heart failure on 02/08/19. Review of Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required total dependence with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #5 also…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-11-14 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interviews, the facility failed to implement a resident's skin integrity care plan. This affected one (Resident #15) of 14 residents reviewed for implementation of care plans. The facility census was 42. Findings include: Record review revealed Resident #15 was admitted to the facility on [DATE] with the following diagnoses; corticobasal degeneration, dementia with lewy bodies, mixed hyperlipidemia, orthostatic hypotension, vitamin D deficiency, insomnia and muscle weakness. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility and dressing. Resident #15 also required supervision with eating and total dependence with transfers, toileting and personal hygiene. Resident #15 was reported to have a stage one pressure area. Review of Resident #15's progress notes dated 10/24/19 revealed the resident developed a small area that was 0.5…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-14 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview the facility failed to ensure staff did not falsify records in regard to dressing changes they did not personally complete. This affected one (Resident #21) of four residents reviewed for skin management. The census was 42. Findings include: Medical record review for Resident #21 revealed she was admitted on [DATE]. Medical diagnoses included peripheral vascular disease, venous insufficiency, and diabetes. Review of annual Minimum Data Set (MDS) dated [DATE] for Resident #21 revealed she was severely cognitively impaired. Her functional status was total dependence for bed mobility, transfers, and toilet use. She was supervision for eating. Further review of this MDS revealed there were two arterial ulcers. Review of the Treatment Administration Record (TAR) for Resident #21 for November 2019 revealed she had daily dressing changes to both heels that were to be completed on day shirt. Further review revealed on 11/12/19, Licensed Practical Nurse…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff, nurse practitioner, and resident interviews, and review of facility policies, the facility failed to ensure staff monitored a wound for signs of infection and failed to report an odor to the physician. This affected one (#Resident 21) of four residents reviewed for skin conditions. The facility census was 42. Findings include: Medical record review for Resident #21 revealed she was admitted on [DATE]. Medical diagnoses included peripheral vascular disease, venous insufficiency, and diabetes. Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #21 revealed she was severely cognitively impaired. Her functional status was total dependence for bed mobility, transfers, and toilet use. She was supervision for eating. Further review of this MDS revealed there were two arterial ulcers. Review of physician orders dated 10/04/19 and discontinued on 10/26/19 revealed Hydrogel to apply to right and left heel topically one time a day. The wounds were to be…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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, observation, staff interview and facility policy review the facility failed to ensure a resident with an indwelling catheter had an order for the catheter and failed to ensure catheter care was provided and/or the catheter was changed on a regular basis. This affected one (#21) of one resident for an indwelling catheter, The facility identified there were two residents with an indwelling catheter. The census was 42. Findings include: Medical record review for Resident #21 revealed she was admitted on [DATE]. Medical diagnoses included peripheral vascular disease, venous insufficiency, and diabetes. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired. Her functional status was total dependence for bed mobility, transfers, and toilet use. She was supervision for eating. She was coded for an indwelling catheter. Review of care plan not dated for an indwelling catheter related to history and potential for skin breakdown…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-14 · tag F0710 — isolated
    Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and staff interviews, the facility failed to ensure a resident's physician evaluated and addressed a resident's significant weight loss. This affected one (Resident #15) of one resident reviewed for nutrition. The facility census was 42. Findings include: Record review revealed Resident #15 was admitted to the facility on [DATE] with the following diagnoses; corticobasal degeneration, dementia with lewy bodies, mixed hyperlipidemia, orthostatic hypotension, vitamin D deficiency, insomnia and muscle weakness. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility and dressing. Resident #15 also required supervision with eating and total dependence with transfers, toileting and personal hygiene. Resident #15 was reported to have a weight loss of five percent or more in the last month or loss of ten percent or more in last six months. Resident #15…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-14 · tag F0711 — isolated
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    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 staff interviews, the facility failed to ensure a resident that discharged from the facility had a written, signed and dated order from the physician. This affected one (Resident #46) of one resident reviewed for discharges to the community. The facility census was 42. Findings include: Record review revealed Resident #46 was admitted to the facility on [DATE] with the following diagnoses; unspecified fall, primary generalized osteoarthritis, vascular dementia without behavioral disturbance, vascular dementia without behavioral disturbance, muscle weakness, hypertension, hyperlipidemia, osteoporosis, iron deficiency, vitamin D deficiency and major depressive disorder. Resident #46 discharged to an assisted living facility on 08/22/19. Review of Resident #46's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-14 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure drug regimen review recommendations were addressed by the attending physician in a timely manner. This affected one (Resident #33) of five residents reviewed for unnecessary medications. The facility census was 42. Findings include: Record review revealed Resident #33 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia with behavioral disturbance, chronic atrial fibrillation, hypertension, major depressive disorder, unspecified macular degeneration, anorexia nervosa, psychosis and diverticulosis. Review of Resident #33's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required supervision with bed mobility, transfers, eating, toileting and personal hygiene. Resident #33 also required limited assistance with dressing. Review of Resident #33's pharmacy recommendation dated 09/20/19 revealed the pharmacy recommended Resident #33's as needed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-14 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure a resident received routine or annual dental services. This affected one (Resident #33) of one resident reviewed for dental services. The facility census was 42. Findings include: Record review revealed Resident #33 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia with behavioral disturbance, chronic atrial fibrillation, hypertension, major depressive disorder, unspecified macular degeneration, anorexia nervosa, psychosis and diverticulosis. Review of Resident #33's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required supervision with bed mobility, transfers, eating, toileting and personal hygiene. Resident #33 also required limited assistance with dressing. The resident had obvious or likely cavity or broken natural teeth. MDS. Review of Resident #33's dental care plan revealed the resident had carious (decayed) and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-11-14 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and facilty menu spreadsheet review, the facility failed to follow menus that were prepared in advance or to notify residents when menu items changes. The facility also failed to follow menu spreadsheets for portion sizes. This had to potential to affect 35 Residents (#3, #4, #5, #6, #8, #9, #11, #12, #13, #15, #16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #31, #32, #33, #34, #35, #36, #37, #39, #40, #41, #42, #43 and #194) who resided in the affected houses (9335, 9336, 9349, and 9350). The facility census was 42. Findings include: 1. Review of House 9336's menu spreadsheet for 11/13/19 revealed residents were to receive 0.5 cup of applesauce, 4 ounces (oz) chicken stir fry, 0.5 cup of fried rice, 4 oz of oriental blended vegetables, three mini egg rolls and a slice of banana bread. Observation on 11/13/19 at 11:27 A.M. revealed State Tested Nurse Aide (STNA) #73 served residents applesauce, chicken stir fry and egg rolls. STNA #73 was observed to give regular and mechanical soft diets an unknown amount of applesauce, an unknown about…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to OTTERBEIN SENIORLIFE — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.2+0.8 vs chain
Health inspection 3 of 53.0≈ chain avg
Staffing 4 of 53.2+0.8 vs chain
Quality measures 5 of 54.1+0.9 vs chain
The other 19 homes this chain runs (chain average 3.2★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
OTTERBEIN HOMEOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 12/01/2021
OTTERBEIN NEIGHBORHOODS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2016
ARNOLD, DANIELIndividualCORPORATE OFFICERsince 09/03/2018
GREEN, JAMESIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 11/21/2005
MILLER, JASONIndividualCORPORATE OFFICERsince 08/04/2014
WILSON, JILLIndividualCORPORATE OFFICERsince 05/01/2009
FUNCTIONAL PATHWAYS OF TENNESSEE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/04/2025
APP, LYNNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
BARTLETT, VICTORIAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
BAYLIFF, BECKYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
BERNER, SUSANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
BROWNSON, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
BURKE, DANIELIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
COLEMAN, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
FRALEY, RALPHIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
GLOSSER, HEIDIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
HAZELBAKER, TOMASIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
MCKINNEY, KRISTENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/06/2025
VONDERHAAR, STEVEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2021
BAKER, STEVEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/04/2025
GALBUT, ABRAHAMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/04/2025
GALBUT, DANIELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/06/2025
GALBUT, DAVIDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/04/2025
GALBUT, ERICIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/06/2025
GALBUT, ROBERTIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/04/2025
PARITZKY, JONATHANIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/04/2025
ROMBRO, DAVIDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/04/2025
ZISEK, TODDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/04/2025
POLARIS PHARMACY SERVICES OF OHIO LLCOrganizationADP OF THE SNFsince 12/01/2018

CMS files one row per role, so the 36 rows in the source record cover these 29 parties — each is shown once here with every role it holds. Nothing is omitted.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$7.3M
Net patient revenuemost recent cost report
+5.7%
Operating marginrevenue minus expenses
$374K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 19%Medicare 13%Other / private 68%

This home reported $374K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$335per resident / day
operating cost
$10,196per month
≈ monthly operating cost
$356per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.

Typical monthly cost in Ohio
$9,186/mo
Nursing home (semi-private)
$10,389/mo
Nursing home (private)
$6,103/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366368. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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