No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Blue Ash Health & Rehab

4900 Cooper Road, Cincinnati, OH 45242 · For profit - Corporation · 64 certified beds · (513) 793-3362 Medicare & Medicaid certified

Call the home — (513) 793-3362 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0610) — most recent Dec 20251 actual-harm citation
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (70%) runs well above the national median (45%)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 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
9500 Kenwood Rd · (513) 773-1214 · Call to confirm hours
Pharmacy
Walgreens0.1 mi
9580 Kenwood Rd · (513) 791-4390 · Call to confirm hours
Grocery
5035 Cooper Rd · (513) 791-3175 · Call to confirm hours
Park
4871 Cooper Rd · (513) 686-1270 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
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 increased10.6%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight2.6%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 symptoms42.5%30.1%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.4%3.2%3.3%worse
Long-stay residents whose ability to walk worsened17.6%6.1%16.1%typical
Long-stay residents on antianxiety or hypnotic medication39.5%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine98.1%94.5%95.3%typical
Long-stay residents with pressure ulcers3.1%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control28.1%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table11.8%8.8%17.1%better
Short-stay residents given the seasonal flu vaccine71.4%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.

0.34U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identifiednot 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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

0.47
RN hours/ resident / day
0.93
LPN hours/ resident / day
2.08
Aide hours/ resident / day
3.48
Total nurse hours/ resident / day
0.50
RN hoursweekends
70.4%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 64 beds and averages 37.7 residents a day — about 59% occupied, or roughly 26 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.483 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 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 3.05 hrs/resident/day on weekends vs 3.66 on weekdays — 17% thinner on weekends. RN hours go from 0.46 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 70% is well above 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

9
deficiencies at the latest standard inspection (2025-07-01)
0
at the previous standard inspection (2023-02-02)

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.

31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.

  • Actual harm · Gcited before2024-08-26 · 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 medical record review, review of hospital records, and resident and staff interviews the facility failed to provide adequate care and services to prevent constipation. This resulted in harm on 08/22/2024 when Resident #15 was sent to the hospital and received treatment for a large fecal impaction. This affected one of three resident sampled for constipation. The facility census was 51. Findings include: Review of the medical record revealed Resident #15, was admitted to the facility on [DATE]. Diagnoses included unspecified neuromuscular dysfunction of the bladder, stage IV sacral pressure ulcer, unstageable pressure ulcer to the left heel, generalized anxiety disorder, unspecified major depressive disorder, and hemiplegia with hemiparesis following cerebral infarction affecting the left non-dominant side. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, occasionally rejected care, and did not wander. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-02 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, and staff interview, this facility failed to ensure documentation of medication being administered was charted in residents' electronic medication administration record. (Emar). This affected 11 residents (Resident #60, #62, #64, #66, #68, #70, #72, #74, #76, #78, and #80) of the 12 residents reviewed for medication administration. The facility census was 35. Findings include:Review of the medical records for Resident #60, #62, #64, #66, #68, #70, #72, #74, #76, #78, and #80 revealed each resident had physician orders to receive nighttime or evening medications. Continued review of each resident's electronic medication administration record revealed medication was not documented as being administered for the evening of 05/26/2026. Attempted contact on 05/29/2026 at 2:10 P.M. and again at 3:20 P.M. with Licensed Practical Nurse (LPN) #131 who was the nurse noted to have worked the evening of 05/26/2026 with no success. A voice message could not be left due to the voice mail box not being set up at that time. Attempted to contacted LPN #116 on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-16 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the facility had hot water in resident areas per resident preferences. This affected 18 residents (#02, #06, #08, #09, #10, #11, #12, #17, #18, #19, #23, #24, #25, #32, #33, #34, #35, and #36) out of 36 residents residing in the facility. The facility census was 36.Interview with Resident #08 on 03/12/26 at 8:17 A.M. revealed the water did not get hot at the facility. Resident #08 stated the water was also cold during bathing.Interview with Resident #11 on 03/12/26 at 8:19 A.M. revealed the water was cold at the facility and did not get hot. Resident #11 stated the water had been cold for approximately two months. Interview with Resident #17 on 03/12/26 at 8:39 A.M. revealed one side of the building had cold water for a long time. Observation of Maintenance Director #70 taking the water temperatures in the facility on 03/12/26 at 9:00 A.M. revealed the water temperature in Resident #02's bathroom was 135.9 degrees Fahrenheit, the water temperature in Resident #06 and Resident #07's bathroom was 69.7…

    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 · E2025-12-11 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, record review, and facility policy review, the facility failed to maintain mechanical equipment to heat residents' rooms. This affected four Residents (#33, #34, #35, and #36) out of four Residents reviewed. The facility census was 40. Findings include:Medical record review for Resident #34 revealed he was admitted to the facility on [DATE]. Diagnoses included quadriplegia, chronic obstructive pulmonary disease (COPD), essential primary hypertension, gastro-esophageal reflux disease (GERD), hyperlipidemia, insomnia, major depressive disorder, diabetes mellitus (DM), and anxiety disorder.Review of the Minimum Data Set (MDS) assessment for Resident #34 dated 11/20/25, revealed he was cognitively intact.Medical record review for Resident #35 revealed he was admitted to the facility on [DATE]. Diagnoses included essential primary hypertension, asthma, intermittent explosive disorder, heart failure, anemia, major depressive disorder, generalized anxiety…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review the facility failed to thoroughly investigate an allegation of abuse. This affected one (Resident #21) of three residents reviewed for abuse. The facility census was 40.Medical record review for Resident #19 revealed she was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, seizure, malignant neoplasm of the intrathoracic lymph node, delusional disorder, atrial fibrillation, essential primary hypertension, and multiple sclerosis.Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 had impaired cognition. Resident #19 was dependent on staff for activities of daily living (ADL).Review of the SRI (control number 266147) created on 10/08/25 at 1:41 P.M. related to an injury of unknown origin identified on 10/08/25. Resident #19 alleged Licensed Practical Nurse (LPN) #97 grabbed her arms during a disagreement and left discoloration. The facility collected statements from LPN #97 and Resident #19.…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, record review, and facility policy review, the facility failed to provide a safe environment related to residents smoking. This affected one (Resident #36) of the one resident observed for smoking. The facility census was 40.Findings include:Medical record review for Resident #36 revealed he was admitted to the facility on [DATE]. Diagnoses included nontraumatic intracerebral hemorrhage, dysphagia, essential primary hypertension, major depressive disorder, hyperlipidemia, congestive heart failure, and diabetes mellitus (DM).Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively intact. Resident #36 was dependent on staff for medication administration. Resident #36 required set up assistance from staff with eating, oral hygiene, toilet use, and supervision with bathing. He was independent with upper body dressing, lower body dressing, and personal hygiene.Review of the active care plan for Resident #36 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-07-01 · 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 policy review, the facility failed to ensure a sanitary environment for preparing and serving food and failed to ensure staff wore hair restraints while in the kitchen. This had the potential to affect all 53 residents who resided in the facility as the facility identified all residents received food from the kitchen. Findings include: Observation on 06/29/25 at 9:36 A.M., of the steam table in the kitchen with Dietary Supervisor (DS) #354, revealed a wooden panel of compressed wood, nailed to the side of the steam table. The top of the wooden panel, located even with the surface of the steam table, and extending the depth of the steam table, was observed to be significantly deteriorated and porous, with a beige fibrous material. Interview with DS #354 at the same time, verified the wooden panel was deteriorated, porous, and was not able to be cleaned. DS #354 stated the wooden panel had been in the stated condition when he started approximately three months prior. Observation on 06/30/25 at 10:26 A.M. with DS #354, revealed a fan, which…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-07-01 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and record review, the facility failed to maintain a facility Tuberculosis (TB) Risk Assessment. This had the potential to affect all 53 residents who resided in the facility. The facility also failed to ensure all newly hired employees were tested for TB and employees employed by the facility for more than a year were screened annually for TB. This affected four (Business Office Manager [BOM] #410, Licensed Practical Nurse [LPN] #305, Certified Nursing Assistant [CNA] #361, and CNA #332) of the five personnel files reviewed. This had the potential to affect all 53 residents of the facility. Findings Include: 1. Interview on 07/01/25 at 2:58 P.M. with the Administrator revealed the facility does not do a Tuberculosis Risk Assessment. Review of the facility provided documentation at the same time with the Administrator, revealed the facility had TB Risk Assessment. Review of the facility policy titled Tuberculosis Risk Assessment (not dated) states a Tuberculosis Risk Assessment shall be conducted annually. 2. Review of BOM #410's personnel file revealed BOM…

    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 · Ecited before2025-07-01 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, resident interview, review of facility documents, and review of the facility policy, the facility failed to ensure comfortable and safe temperatures were maintained throughout the facility in resident rooms and common areas. This had the potential to affect the 10 residents residing on the facility's A-hall (#03, #04, #07, #13, #16, #26, #36, #52, #204, and #206), the 13 residents residing on the facility's B-hall (#01, #02, #10, #17, #19, #24, #29, #35, #37, #39, #43, #47, and #50. The facility identified 16 residents who routinely ate meals in the dining room (#01, #02, #06, #11, #12, #15, #16, #20, #27, #30, #36, #37, #39, #40, #46, and #47). The facility census was 53 residents. Findings include: Observation on 06/29/25 at 10:35 A.M. revealed the Administrator was taking air temperatures with an infrared laser digital thermometer with the following results: 86.9 degrees Fahrenheit (F) at the beginning of A-hall, closest to the entrance of the building, 81.7 degrees in the second half of A-hall adjacent to the nurses' station, 84.9 degrees F…

    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 · D2025-07-01 · tag F0579 — isolated
    Provide information about how to apply for and use Medicare and Medicaid benefits.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff interview, resident interview, and review of the facility policy, the facility failed to provide residents with information regarding how to apply for Medicaid benefits. This affected one (Resident #53) of two residents reviewed for discharge. The facility census was 53. Findings include: Review of the medical record for Resident #53 revealed an admission date of 11/20/24 with diagnoses including chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), opioid dependence, cocaine abuse, pulmonary hypertension, bipolar disorder and post-traumatic stress disorder and a discharge date of 04/02/25. Review of a notice of adverse determination from the Medicaid provider for Resident #53 dated 03/28/25 revealed the resident no longer needed daily nursing care and her care needs could be met in a lower level of care. The document also included information for the resident with the opportunity to file a grievance against the decision or appeal the decision. Review of a social 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-01 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of Self-Reported Incidents (SRIs), review of personnel files, review of the Bureau of Criminal Investigation (BCI) background check logs, staff interview, and review of the facility policy, the facility failed to implement their policy by failing to conduct criminal background checks. This affected two (Residents #08 and #156) of three residents reviewed for abuse. The facility census was 53 residents. Findings include: Review of the facility SRI dated 01/31/25 revealed the facility substantiated an allegation of misappropriation of funds from Resident #08 and #156's resident fund accounts per Business Office Manager (BOM) #410. The facility contacted the local police who investigated the allegation, BOM #410, was terminated, and the facility replaced the residents' funds. Review of the personnel file for BOM #410 revealed a hire date of 12/16/24 and a termination date of 02/03/25. The file did not include a criminal background check completed upon hire for BOM #410. Review of the facility BCI log revealed BOM #410 was hired on 12/16/24, but BCI checks were not…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · D2025-07-01 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff interview, resident interview, and review of the facility policy, the facility failed to ensure a safe and orderly discharge. The affected one (Resident #53) of two residents reviewed for discharge. The facility census was 53 residents. Findings include: Review of the medical record for Resident #53 revealed an admission date of 11/20/24 with diagnoses including chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, chronic obstructive pulmonary disease, opioid dependence, cocaine abuse, pulmonary hypertension, bipolar disorder and post-traumatic stress disorder. The resident was discharged from the facility on 04/02/25. Review of the physician's orders for Resident #53 revealed an order dated 01/27/25 for oxygen at three liters per minute via nasal cannula every shift. Review of a notice of adverse determination from the Medicaid provider for Resident #53 dated 03/28/25 revealed the resident no longer needed daily nursing care and that her care needs could be met at a lower level of care. The document also provided the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-01 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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, resident interview, and review of the facility policy, the facility provide an accurate notice of discharge to a resident before discharge and failed to provide a copy of the discharge notice to the Ombudsman. This affected one (Resident #53) of two residents reviewed for discharge. The facility census was 53 residents. Findings include: Review of the medical record for Resident #53 revealed an admission date of 11/20/24 with diagnoses including chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, chronic obstructive pulmonary disease, opioid dependence, cocaine abuse, pulmonary hypertension, bipolar disorder and post-traumatic stress disorder. The resident was discharged from the facility on 04/02/25. Review of the Minimum Data Set (MDS) assessment for Resident #53 dated 04/02/25 revealed the resident had an unplanned discharge. Resident #53 had intact cognition, was always continent of bowel and bladder was independent for eating,…

    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 · D2025-07-01 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff, resident and physician interviews and record review, the facility failed to conduct pain assessments and administer pain medication as ordered. This affected one (#36) of the two residents reviewed for pain medication administration. The facility census was 53. Findings include: Review of the medical record for Resident #36 revealed the resident was admitted on [DATE]. Diagnoses included anxiety disorder, type two diabetes mellitus with diabetic peripheral angiopathy, hypertension, arthritis and schizophrenia. Review of the care plan for Resident #36 dated 04/28/25, revealed the resident was at risk for increase in behaviors of irritability, agitation, restlessness, grimacing, hyperventilation, groaning or crying without relief of pain. Interventions included administering medication as ordered and notify the physician if interventions were unsuccessful or unable to be fulfilled. Review of the Minimum Data Set (MDS) assessment for Resident #36 dated 06/10/25, revealed the 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-01 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interviews, and review of the facility policy, the facility failed to ensure insulin vials were properly labeled and stored. This affected one (#29) of the five residents who received Insulin stored in the A/B medication cart and of the 24 residents with medications stored in the A/B medication cart. The facility census was 53. Findings include: Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II, cerebral infarction and atrial fibrillation. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #29 had moderate cognitive impairment and was dependent on staff for medications. Review of physician orders for Resident #29 revealed an order dated 05/22/25 for Lantus SoloStar subcutaneous solution pen-injector 100 unit/milliliter (ml) inject 10 units subcutaneously at bedtime related to diabetes mellitus type II with hyperglycemia. Review of the May…

    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 · Fcited before2025-04-16 · 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 observations, staff interview, and review of facility policy, the facility failed to provide clean, sanitary kitchen. This had the potential to affect all 55 residents residing in the facility who receive food from the kitchen. Findings include: During an observations of the kitchen on 03/25/25 at 11:08 A.M., the floor was dirty with food crumbs scattered on floor, cracks on the floor, dirt was smeared all over the floor, the trash can which was full of trash had no lid. A hair net was lying on the floor next to the trash can. There was a dirty bath blanket and four towels with black unknown substance on them in a pile under the kitchen sink next to prep table. Interview on 03/25/25 at 11:30 A.M. with [NAME] #134 verified there was a blanket and towels under the sink. [NAME] #234 stated there was a big accident in the kitchen and there was spillage on the floor. Review of the policy titled Dietary Food Preparation Area, undated, revealed the facility will maintain a clean, sanitary and safe food preparation area. The facility was to have a sink hot water and soap…

    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 before2025-04-16 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and policy review, the facility failed to ensure a resident was provided the correct diet texture. This affected one (Resident #52) of three residents reviewed. The facility census was 55. Findings include: Review of the medical record for Resident #52 revealed admission date 05/25/24. Diagnoses included pneumonitis, anxiety disorder, type two diabetes, hemiplegia, and hemiparesis. Review of plan of care dated 12/10/24 revealed Resident #52 was at risk for nutrition and hydration problems related to diabetes mellitus, schizoaffective disorder, bipolar, need for nutritional supplements, supervision for all meals, nosey cup with drinks, and need for mechanically altered diet and thickened liquids. Interventions include allowing residents to make choices, or preferences, observe any signs and symptoms of choking, provide assisted devices with meals, obtain weights as ordered, speech therapy screen as need, and weekly weights. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/04/25, revealed that Resident #52 was severely cognitively…

    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 before2025-04-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, interview, and policy review, the facility failed to implement fall prevention interventions for residents. This affected one (Resident #46) of three residents reviewed for falls. The facility census was 55. Findings include: Record review revealed Resident #46 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, Schizophrenia disorder, disturbance psychotic disorder, anxiety disorder, irritable bowel syndrome, dementia, and pseudobulbar affect. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/18/24, revealed that Resident #46 was cognitively impaired. Resident #46 required maximal assistance for meals, oral care, personal hygiene, and dressing upper body. Resident #46 was dependent for dressing lower body, bathing, placing shoes on and off, and toileting hygiene. Review of the plan of care dated 02/07/25 revealed Resident #46 was at risk for falls related to Alzheimer's disease, impaired gait balance, impaired vision,…

    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 · E2025-01-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure oxygen was administered as ordered by a physician and in accordance with professional standards of practice for respiratory care. This affected three (Residents #3, #14, and #18) of three residents reviewed for oxygen administration. The facility census was 51 residents. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 11/20/24 with diagnoses including acute infarction of intestine due to gunshot wound, cocaine abuse, opioid dependence, bipolar disorder, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, severe protein-calorie malnutrition and pulmonary hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #14 dated 12/01/24 revealed the resident was cognitively intact and required assistance with activities of daily living (ADLs). Review of the plan of care for Resident #14 dated 12/18/24 revealed the resident had altered respiratory status related to COPD with a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-20 · tag F0622 — isolated
    Not 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

    Based on medical record review, resident representative interview, staff interview, and review of the facility policy, the facility discharged a resident from the facility without a physician's order or proper documentation of a rationale for the facility-initiated discharge. This affected one (Resident #42) of two residents reviewed for transfer or discharge. The facility census was 51 residents. Findings include: Review of the medical record for Resident #42 revealed an admission date of 08/18/23 with diagnoses including unspecified encephalopathy, dementia, mood affective disorder and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #42 dated 10/03/24 revealed the resident had severe cognitive impairment and required staff assistance with activities of daily living (ADLs.) Review of the progress notes for Resident #42 dated 08/18/24 to 01/10/25 revealed they did not include documentation of a discharge notice from the facility to the resident nor did they include any documentation of a reason for discharge. Review of the physician's orders for Resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-20 · tag F0623 — isolated
    Provide 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

    Based on medical record review, resident representative interview, staff interview, and review of the facility policy, the facility discharged a resident from the facility and failed to a written notice of discharge to the resident and resident representative before the discharge. This affected one (Resident #42) of two residents reviewed for transfer or discharge. The facility census was 51 residents. Findings include: Review of the medical record for Resident #42 revealed an admission date of 08/18/23 with diagnoses including unspecified encephalopathy, dementia, mood affective disorder and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #42 dated 10/03/24 revealed the resident had severe cognitive impairment and required staff assistance with activities of daily living (ADLs.) Review of the progress notes for Resident #42 dated 08/18/24 to 01/10/25 revealed they did not include documentation of a discharge notice from the facility to the resident nor did they include any documentation of a reason for discharge. Review of the physician's orders for…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-27 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview, the facility failed to have a Registered Nurse (RN) on duty for eight consecutive hours every day. This had the potential to affect all residents residing in the facility. The facility census was 52 residents. Findings include: Review of the staffing schedule dated 10/26/24 through 10/31/24 revealed the facility did not have an RN scheduled on 10/26/24 and 10/27/24. Interview on 11/27/24 at 12:21 P.M. with [NAME] President of Operations (VPO) #35 confirmed the facility did not have an RN work on 10/26/24 and 10/27/24. This deficiency represents noncompliance investigated under Complaint Number OH00159379.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-27 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview, the facility failed to ensure residents' Medicaid coverage was maintained. This affected two (Residents #14 and #15) out of three residents reviewed for payor source. The facility census was 52 residents. Findings include: Review of the medical record for Resident #14 revealed an admission date of 05/20/24 with diagnoses including insomnia, psychosis, anxiety, depression, and schizophrenia. Review of the Minimum Data Set (MDS) assessment for Resident #14 dated 08/27/24 the resident was cognitively intact and required extensive assistance with activities of daily living (ADLs). Review of the medical record for Resident #15 revealed an admission date of 06/08/23 with diagnoses including encephalopathy, diabetes mellitus, and cerebral infarction. Review of the MDS assessment for Resident #15 dated 10/03/24 revealed the resident was severely cognitively impaired deficits and required extensive assistance to total dependence with ADLs. Review of the facility daily census dated 11/26/24 revealed Resident #14 and Resident #15 had Medicaid…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff followed guidelines for wearing personal protective equipment (PPE) during care for residents on enhanced barrier precautions (EBP.) This affected one (Resident #16) of three residents reviewed for catheter care. The facility census was 52 residents. Findings include: Review of the medical record for Resident #16 revealed an admission date of 10/14/24 with diagnoses including depression, neuromuscular dysfunction of bladder, and paraplegia. Review of the Minimum Data Set (MDS) assessment for Resident #16 dated 10/21/24 revealed the resident had no cognitive deficits and required substantial assistance to total dependence with activities of daily living (ADLs). Observation of catheter care for Resident #16 on 11/27/24 at 11:07 A.M. per Certified Nursing Assistant (CNA) #40 revealed the resident was in EBP due to the catheter and the aide did not wear a gown while providing direct care to the resident. Interview on 11/27/24 at 11:10 A.M. with CNA #40…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-26 · 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 observation, review of the medical record, resident and staff interview, and policy review, the facility failed to ensure urine collection bags were stored in a sanitary manner. The facility identified one resident (Resident #15) with a catheter. The facility census was 51. Findings include: Review of the medical record revealed Resident #15, was admitted to the facility on [DATE]. Diagnoses included neuromuscular dysfunction of the bladder, stage IV sacral pressure ulcer, unstageable pressure ulcer to the left heel, generalized anxiety disorder, unspecified major depressive disorder, and hemiplegia with hemiparesis following cerebral infarction affecting the left non-dominant side. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, occasionally rejected care, and did not wander. Resident #15 had an indwelling catheter. Urinary continence was not rated. Resident #15 was frequently incontinent of bowel and was not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-29 · 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 review of time sheets, staff interviews and policy review, the facility failed to ensure staff completed medication counts at shift change and failed to ensure narcotic lock box keys were securely locked when not in possession of the designated nurse. This had the potential to affect 17 (#29, #23, #25, #24, #39, #28, #27, #41, #31, #42, #37, #32, #40, #30, #45, #35, and #34) residents who had narcotics stored on the medication cart and 32 (#29, #3, #20, #46, #23, #37, #36, #32, #22, #33, #13, #1, #38, #47, #8, #21, #44, #5, #16, #25, #24, #39, #15, #28, #10, #43, #27, #26, #12, #19, #4, and #17) residents who were ambulatory or could self-propel with mobility assistive devices and that could access the medication cart. The census was 45. Findings include: 1. Review of time sheets dated 12/12/23 revealed Licensed Practical Nurse (LPN) #127 clocked in at 7:15 A.M. and clocked out at 11:15 P.M. LPN #123 clocked in at 12:00 A.M. and clocked out at 6:30 A.M. Interview on 12/29/23 at 10:05 A.M. LPN #127 stated she worked overtime on 12/12/23 because there had been some confusion…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-26 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure the required Minimum Data Set (MDS) assessments were completed in a timely manner. This affected one (#124) of 17 residents reviewed for assessment. The facility census was 22. Findings include: Review of the medical record of Resident #124 revealed an admission date of 08/04/22. Diagnoses included diabetes mellitus with bilateral diabetic macular edema, psychotic disorder with hallucinations, essential hypertension, altered mental status, unspecified symptoms and signs involving cognitive functions and awareness. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. The resident required supervision for bed mobility, limited assistance for transferring, eating, and toileting. The resident was assessed as having severely impaired vision 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-26 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interview and review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately complete the Minimum Data System (MDS) information. This affected one (#7) of 17 residents assessments reviewed. The facility census was 22. Findings included: Review of Resident #7's medical record revealed an admission date of 10/30/22. admission diagnoses included chronic obstructive pulmonary disease, anxiety disorder, alcohol abuse, bipolar disorder, and hypothyroidism. Review of Resident #7's Minimum Data Set (MDS) 07/06/22 revealed a Brief Interview Mental Status (BIMS) of fifteen which indicated the resident was cognitively intact. The MDS revealed the resident required total dependence with two-person physical assistance for transfer. The resident required extensive one-person assistance with bed mobility and total dependence with one-person assistance for dressing,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-08-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, record review and review of policy, the facility failed to ensure smoking materials were secured. This affected one (#16) of 13 residents identified by the facility, who smoked at the facility. The facility census was 22. Findings included: Review of Resident #16's medical record revealed an admission date of 05/14/14. Resident #16's diagnoses included: nicotine dependence of cigarettes, chronic rhinitis, muscle spasm, malaise, personal history of COVID-19, aphasia, spastic hemiplegia affecting the right dominant side, cognitive communication deficit, muscle weakness, symbolic dysfunctions, difficulty in walking, dementia without behavioral disturbance and alcohol abuse. Review of Resident #16's annual Minimum Data Set (MDS) assessment completed on 07/24/22 revealed the resident had moderate cognitive impairment, required supervision with setup help for bed mobility, walking, locomotion, and eating. Resident #16 needed limited assist of one staff for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-26 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to ensure laboratory test were completed as ordered. This affected one (#6) of five residents reviewed for unnecessary medication. The facility census was 22. Findings included: Review of Resident #6's medical record revealed an admission date of 05/12/22, with diagnoses including: type II diabetes with hyperglycemia, malignant neoplasm of part of the left bronchus or lung, cirrhosis of the liver, atherosclerotic heart disease of the native coronary artery, hypothyroidism, personal history of malignant neoplasm of the breast, hypertension, morbid obesity, iron deficiency anemia secondary to blood loss, intestinal malabsorption, lactose intolerance, primary osteoarthritis, hyperlipidemia, angiodysplasia of the stomach and duodenum, Vitamin D deficiency and nontoxic single thyroid nodule. Review of the Physician Monthly Order Summary Report for August 2022 revealed an order dated 03/16/22 for a Complete Blood Count (CBC) and Comprehensive Metabolic Profile (CMP) every Monday. Review of the laboratory results in the…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-08-26 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 the vets were maintained in a clean manner. This had the potential to affect 22 of 22 residents in the facility. The facility census was 22. Findings include: 1. Observation on 08/22/22 at 8:25 A.M., in the kitchen, revealed the vents of the hood above the stove and grill in the kitchen were coated in a grey and black textured substance. Further observation revealed a sticker on the hood, indicating the hood was last professionally cleaned in April 2021. Interview with [NAME] #09, at the time of the investigation, verified the vents of the hood were dirty and needed to be cleaned and stated he was unsure when the last time it was, that the hood vents were cleaned. 2. Observation on 08/23/22 at 11:53 A.M., in the kitchen, revealed a vent, approximately 20 inches squared and six feet high, was coated in a grey and furry textured substance. The vent was directed toward the tray line. Interview with Dietary Supervisor (DS) #33, at te time of the observation, verified the vent was dirty and needed 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.

    Environmental Deficiencies · Deficient, Provider has plan 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 BAO OPCO HOLDINGS — 3 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 1 of 52.0-1.0 vs chain
Health inspection 2 of 52.3-0.3 vs chain
Staffing 1 of 51.7-0.7 vs chain
Quality measures 4 of 53.3+0.7 vs chain
The other 2 homes this chain runs (chain average 2.0★, 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
BAO OPCO HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 06/30/2025
SMITHEY, ASHLEYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF25%since 06/30/2025
WOMACK, BRYONIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF75%since 06/30/2025
OHIO-TWO PROPERTIES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/30/2025
RISE SNF MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/30/2025
BERNER, SUSANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/30/2025
DENNY, AMBERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/30/2025
KOTHARI, ZAHIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/30/2025
MURPHY, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/30/2025

CMS files one row per role, so the 20 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$3.1M
Net patient revenuemost recent cost report
-34.4%
Operating marginrevenue minus expenses
$240K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 83%Medicare 1%Other / private 15%

About 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $240K paid to related parties (affiliated landlords or management companies) in its most recent 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

$332per resident / day
operating cost
$10,106per month
≈ monthly operating cost
$247per 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 365218. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-01, 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.

What to do next