Brookside Healthcare Center
315 Lilienthal Street, Cincinnati, OH 45204 · For profit - Individual · 105 certified beds · (513) 471-8667 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 1.3% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 1.9% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 24.4% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.4% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 1.6% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 31.6% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.9% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.5% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.0% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.4% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.6% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 63.6% | 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.
Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 9% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not 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 SNF | not 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not 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 worsened | not 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 hospitalization | not 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 SNFs | not 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
How full it usually is: this home is certified for 105 beds and averages 99.6 residents a day — about 95% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.21 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 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 3.02 hrs/resident/day on weekends vs 3.29 on weekdays — 8% thinner on weekends. RN hours go from 0.38 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 29% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · G2022-07-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of information from the National Pressure Injury Advisory Panel (NPIAP), and policy review, the facility failed to assess and monitor a newly applied lower left extremity immobilizer for a pressure area. This resulted in Actual Harm when Resident #57 was readmitted to the facility with a left lower extremity immobilizer on 03/25/22. The immobilizer was not checked for skin breakdown causing a subsequent avoidable unstageable pressure ulcer that was found on 04/06/22. This affected one (Residents #57) of two residents reviewed for pressure ulcer care. The facility census was 93. Findings included: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified asthma, chronic obstructive pulmonary disease, aphasia, coronavirus, insomnia, dysphagia, mild cognitive impairment, muscle wasting and atrophy and anxiety disorder. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-04-17 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure 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, record review and interview, the facility failed to ensure portion sizes were served as planned. This had the potential to affect all 94 residents in the facility. Findings include: Review of the dietary spreadsheet for the breakfast meal on 04/17/25 revealed the serving sizes for the scrambled eggs was 1/4 cup, ground ham was a #16 scoop (1/4 cup), pureed ham was a #16 scoop, pureed eggs was a #16 scoop, and pureed muffin was a #16 scoop. During an observation on 04/17/25 at 8:00 A.M., the breakfast tray line revealed [NAME] #24 utilized #8 scoops (1/2 cup) for the ground ham, pureed ham, and pureed eggs and #12 scoops (1/3 cup) were utilized for the scrambled eggs and pureed muffins. During an interview on 04/17/25 at 8:06 A.M., Registered Dietitian (RD) #330 verified [NAME] #24 was not utilizing the correct size scoops for the ground ham, pureed ham, pureed eggs, scrambled eggs, and pureed muffins. During an interview on 04/17/25 at 8:08 A.M., [NAME] #24 stated he utilizes the dietary spread sheets to determine scoop sizes, however got mixed up and was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review, the facility failed to maintain infection control principles during tracheostomy care. This affected one (Resident #19) of one resident observed for tracheostomy care. The facility identified one resident who currently has a tracheostomy. The facility census was 94. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of tracheostomy, stenosis of larynx, post-procedural subglottic stenosis, paranoid schizophrenia, drug induced dyskinesia and morbid obesity. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #19 had intact cognition and was always continent of bowel and bladder. The resident required supervision with eating, oral and personal hygiene, toileting, bathing, dressing, bed mobility and transfers. Review of physician orders revealed an order dated 02/22/24 for Resident #19 to have her tracheostomy inner cannula cleansed during…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-07-27 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and staff interview, the facility failed to ensure infection control precautions were followed and failed to ensure staff wore personal protective equipment (PPE) to prevent the spread of coronavirus (COVID-19). This affected four (Residents #80, #37, #31 and #33) residents and had the potential to affect all residents it the facility. The census was 93. Findings include: 1. Review of the facility's COVID19 line list revealed Resident #80 tested positive for covid on 07/17/22 and had a cough. Resident #37 did not have covid. During observation of the third floor of the facility on 07/18/22 at 4:09 P.M., Resident #80 was walking in the hall wearing a cloth mas. Resident #80 went to the outdoor smoking area and sat next to Resident #37. Resident #80 and Resident #37 were smoking without a staff member present while sitting approximately three feet apart. During interview on 07/18/22 at 4:09 P.M., Licensed Practical Nurse (LPN) #110 verified Resident #80 was sitting next to Resident #37 outside while smoking and were not socially distanced. LPN #110…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-07-27 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 record review, observation, interview and policy review, the facility failed to appropriately secure and store resident medications which had the potential to affect all residents on the 400 [NAME] Hall (#2, #3, #5, #12, #17, #18, #19, #20, #32, #35, #36, #40, #41, #43, #46, #47, #52, #53, #54, #61, #63, #75, #81, #87, #88.) The facility also failed to discard expired medication which had the potential to affect all residents receiving medications from the 3 East medication cart (#9, #10, #13, #21, #22, #24, #25, #28, #30, #57, #64, #65, #68, #69, #72, #85, #341, #342) The census was 93. Findings include: 1. Observation on [DATE] at 9:07 A.M. revealed the 400 Hall [NAME] medication cart was unlocked and unattended and there was a plastic cup sitting on top the cart containing two tablets. Interview on [DATE] at 9:13 A.M. with Licensed Practical Nurse (LPN) #130 confirmed she had left the cart unlocked and unattended and the medications sitting on top of the cart included an iron tablet and a vitamin D…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-07-27 · tag F0802 — failed to prepare enough nourishing food — patternProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of facility meal times, the facility failed to ensure resident meals were delivered timely. This had the potential to affect 91 of 93 residents who received meals from the kitchen. The facility identified two residents (#27 and #44) who did not received food from the kitchen. The facility census was 93. Findings include: Observations made on 07/18/22 from 12:30 P.M. to 1:11 P.M. revealed dietary staff delivered meal carts to the 300-Unit at 12:30 P.M., the 400-East Unit at 12:58 P.M., and The 400-West Unit at 1:11 P.M. Observation on 07/20/22 at 1:42 P.M. revealed Dietary staff delivered the meal cart to 400-West Unit. Interviews on 07/18/22 from 10:32 A.M. to 12:16 P.M. Residents #5 and #18 complained that meals were late. Interview on 07/20/22 at 1:48 P.M. State Tested Nurse Aide (STNA) #42 stated when he first started working they made trays in the kitchenette on the unit , but after COVID , it all changed. The kitchen never notified when they make substitutes to the menus and the trays were always late. It happened all the time. During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-07-27 · tag F0803 — failed to meet residents' dietary needs — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure residents received food items as printed on the dietary ticket and the facility failed to provide food portions and therapeutic diets as planned by the dietitian. This affected one (Resident #41) of six residents reviewed for dietary services, and this had the potential to affect 91 of 93 residents who received meals from the kitchen. The facility identified two residents (#27 and #44) who did not received food from the kitchen. The facility census was 93. Findings include: 1. Resident #41 admitted to the facility on [DATE] with diagnoses including schizoaffective disorder bipolar type, paranoid schizophrenia, dementia with behavioral disturbances, Barrett's esophagus without dysplasia, and impulsiveness. Review of the most recent Minimum Data Set (MDS) assessment, dated 06/30/22 revealed Resident #41 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #41 was frequently incontinent of B&B…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-07-27 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to label and date stored foods, discard expired foods and maintain kitchen sanitation. This had the potential to affect 91 residents who received food from the kitchen. The facility census was 93. Findings include: Observation on 07/18/22 at 8:45 A.M. revealed following in the main kitchen areas: 1. No hand soap or drying towels at the employee hand sink 2. Three-hole dish washing temperature log completed to 07/12/22 3. Opened cheese slices undated 4. Opened Medpass supplement undated 5. Open taco sauce dated 03/10/22 6. Nine covered plated salads undated 7. Three sealed meat packages in a pan of water in a sink During interview on 07/18/22 at 8:45 A.M., Assistant [NAME] #49 and Diet Manager, (DM) #42 verified the undated and expired foods. Assistant [NAME] #49 verified the meat should have been thawed running water. [NAME] #126 verified there should have been soap and towels at the employee hand sink. Observation on 07/19/22 at 6:55 A.M.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-27 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 the physician was notified of abnormal resident blood sugars as ordered. This affected one (Resident #82) of 16 residents with orders for routine blood sugar monitoring. The census was 93. Findings include: Review of the medical record for Resident #82 revealed an admission date of 12/03/21 with a diagnosis of diabetes mellitus. Review of the Minimum Data Set (MDS) for Resident #82 dated 06/12/22 revealed resident was cognitively intact and required limited assistance of one staff with activities of daily living. Review of physician exam note for Resident #82 dated 07/20/22 revealed resident was being treated in the facility for chronic medical problems which included diabetes and a history of diabetic foot ulcers. The physician's plan for diabetic management included to monitor blood sugars and administer insulin as ordered. Review of July 2022 monthly physician's orders for Resident #82 revealed an order dated 01/20/22 for inulin lispro per sliding scale: If blood sugar was under 80, call physician.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-27 · tag F0637 — isolatedAssess the resident when there is 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 interview, the facility failed to complete and transmit a significant change Minimum Data Set (MDS) assessment for a resident that was admitted to hospice services. This affected one (Resident #57) of 19 residents reviewed for assessments. The facility census was 93. Findings include: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified asthma, chronic obstructive pulmonary disease, aphasia, coronavirus, insomnia, dysphagia, mild cognitive impairment, muscle wasting and atrophy and anxiety disorder. Review of Resident #57's quarterly Minimum Data Set (MDS) assessment, dated 05/22/22, revealed the resident was severely cognitively impaired and was totally dependent with bed mobility, dressing, and toileting. Resident #57 required extensive assistance with eating, and personal hygiene and transfers did not occur during the MDS timeframe.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-07-27 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure the resident assessment was accurate regarding the presence of gastrostomy tubes (g-tubes.) This affected one (Resident #33) of three residents in the facility with g-tubes. The census was 93. Findings include: Review of the medical record for Resident #33 revealed an admission date of 04/14/22 with a diagnosis of malignant neoplasm of the nasal cavity. Review of the Minimum Data Set (MDS) for Resident #33 dated 04/21/22 revealed resident was cognitively intact and required assistance of staff with activities of daily living. Review of section K of the MDS for Resident #33 revealed resident was coded as negative for the presence of a feeding tube. Review of admission nursing assessment for Resident #33 dated 04/14/22 revealed resident had a g-tube in his abdomen present upon admission. Observation on 07/18/22 10:51 A.M. of Resident #33 revealed resident had a g-tube inserted in his abdomen. During interview on 07/18/22 at 10:51 A.M., Resident #33 confirmed resident was admitted to the facility with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2022-07-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, interview and policy review, the facility failed to ensure dependent residents were provided with adequate toenail care. This affected one (Resident #33) of 19 residents sampled. The census was 93. Findings include: Review of the medical record for Resident #33 revealed an admission date of 04/14/22 with a diagnosis of malignant neoplasm of the nasal cavity. Review of the Minimum Data Set (MDS) for Resident #33 dated 04/21/22 revealed resident was cognitively intact and required assistance of staff with personal hygiene. Review of admission physician orders for Resident #33 dated 04/14/22 revealed an order for resident to have a podiatry consult. Review of the care plan for Resident #33 dated 05/04/22 revealed resident had an activities of daily living (ADL) self-care performance deficit. Interventions included staff would provide assistance with grooming, dressing, bathing, locomotion, and ambulation. Observation on 07/20/22 at 8:35 A.M. of Resident #33 with Licensed Practical Nurse (LPN) #110 revealed resident's toenails were thick and mycotic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to ensure residents smoked safely and in designated smoking areas. This affected one (Resident #39) of 39 residents reviewed for smoking. The facility census was 93. Findings include: Record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, traumatic subdural hemorrhage with loss of consciousness of unspecified duration initial encounter, unspecified bacterial pneumonia, chronic viral hepatitis C, schizoaffective disorder, difficulty in walking, other psychoactive substance abuse, acidosis, generalized anxiety disorder and nicotine dependence. Review of Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #39 was independent with activities of daily living. Review of Resident #39's smoking care plan dated 05/12/22 revealed Resident #39 used nicotine products and was known to smoke off and in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-27 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, interview and policy review, the facility failed to ensure residents were provided with adequate care and management of gastrostomy tubes (g-tubes.) This affected one (Resident #33) of three residents in the facility with g-tubes. The census was 93. Findings include: Review of the medical record for Resident #33 revealed an admission date of 04/14/22 with a diagnosis of malignant neoplasm of the nasal cavity. Review of the Minimum Data Set (MDS) for Resident #33 dated 04/21/22 revealed resident was cognitively intact and required assistance of staff with activities of daily living (ADLs.) Review of section K of the MDS for Resident #33 revealed resident was coded as negative for the presence of a feeding tube. Review of admission nursing assessment for Resident #33 dated 04/14/22 revealed resident had a g-tube in his abdomen present upon admission. Review of monthly physician orders for Resident #33 for July 2022 revealed the orders did not include orders for care and management of resident's g-tube. Review of the dietary progress note 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.
- Potential for harm · F2019-11-26 · tag F0729 — widespreadVerify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on personnel file review and staff interview, the facility failed to ensure a state tested nursing assistant (STNA) had an active nurse aide registry. This affected one (#25) out of three STNA personnel files reviewed. This had the potential to affect all residents residing in the facility. The facility census was 54 residents. Findings include: Review of the personnel file of STNA #25, revealed a hire date of 06/21/17. Review of the nurse aide registry, revealed the STNA had an original approval date of 06/26/15 with an expiration date of 08/27/19. There was no updated nurse aide registry verification in the STNA #25's file. During interview with the Human Resources Manager #5 on 11/26/19 at 10:15 A.M., she stated the facility failed to submit STNA #25's required work verification for the past two years. She further stated upon contacting the nurse aide registry staff, she was told to submit proof the STNA had worked at the facility for the past two years along with her 12 hours annual in-service records so she could be placed on the registry. The facility confirmed this had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-26 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a residents advanced directive regarding code status matched in the medical record. This affected (#33) of 18 residents reviewed for physician's orders. The facility census was 54. Findings include: Medical record review revealed Resident #33 was admitted on [DATE] with diagnosis including dementia, coronary artery disease, asthma, osteoarthritis, depression, benign prostatic hyperplasia, anxiety, hypothermia, malnutrition, pain, anemia, hypertension, mood disorder, acute respiratory failure, and hypoxia, gastro-esophageal reflux disease. Review of the Quarterly Minimum Data Set, dated [DATE] revealed that Resident #33 has severe cognitive deficits, requires extensive assistance with activities of daily living, and is always incontinent of bowel and bladder. Review of physician's orders dated 02/12/19 revealed that Resident #33 was listed as a Don't Not Resuscitate (DNR)-Comfort Care Arrest (CCA) remaining active. Further review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-26 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide a copy of the transfer or discharge notification to the Ombudsman for discharges from the facility. This affected two (#12 and #50) of three residents reviewed for discharge notification. The facility census was 54. Findings include: 1. Record review revealed Resident #12 was admitted to the facility on [DATE] with the following diagnoses; displaced intertrochanteric fracture of left femur, chronic obstructive pulmonary disease, schizophrenia, essential hypertension, other cerebrovascular disease, gastro esophageal reflux disease, age related osteoporosis, generalized anxiety disorder, vascular dementia without behavioral disturbance, bipolar disorder muscle weakness, abnormal posture and major depressive disorder. Review of Resident #12's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and require extensive assistance with bed mobility, transfers, 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.
- Potential for harm · Dcited before2019-11-26 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a resident's hospice services were accurately coded on their significant change Minimum Data Sets (MDS) assessment. This affected one (#3) of 18 residents reviewed for accuracy of assessments. The facility census was 54. Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with the following diagnoses; congestive heart failure, gastroesophageal reflux disease, diabetes mellitus, muscle weakness, other symbolic dysfunctions, other chronic pain and dysphagia. Review of Resident #3's significant change Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and require extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #3 also required limited assistance with eating. Further review of Resident #3's 08/29/19 MDS revealed resident did not receive hospice services. Review of Resident #3's chart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-26 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based of medical record review, observation, and staff interview the facility failed to have physician orders for wound care orders in place on admission. This affected one (#152) out of four residents reviewed for wound care. The facility in-house census was 54. Findings include: A chart review revealed Resident #152 was admitted on [DATE] with diagnosis including left hip replacement, respiratory failure, neuromuscular dysfunction of the bladder, hypotension, hyperlipidemia, intestinal obstruction, depression, hypertension, Methicillin resistance staph areolas, tachycardia, kidney failure, acute cystitis, bacteremia, sepsis, and alcoholic cirrhosis. Review of the five day minimum data set (MDS) assessment dated [DATE] revealed Resident #152 has no cognitive deficits, required limited to substantial assistance with activities of daily living, has a catheter for bladder, and is always continent with bowel. Review of care plan dated 11/20/19 revealed Resident #152 has actual alteration in skin integrity related…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-26 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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 medical record review and staff interview, the facility failed to ensure drug regimen review recommendations were appropriately addressed by the attending physician. This affected one (#33) of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: Medical record review revealed Resident #33 was admitted on [DATE] with diagnosis including dementia, coronary artery disease, asthma, osteoarthritis, depression, benign prostatic hyperplasia, anxiety, hypothermia, malnutrition, pain, anemia, hypertension, mood disorder, acute respiratory failure, and hypoxia, gastro-esophageal reflux disease. Review of the Quarterly MDS dated [DATE] revealed that Resident #33 has severe cognitive deficits, requires extensive assistance with activities of daily living, and is always incontinent of bowel and bladder. Review of Pharmacy Monthly Reviews dated 06/2019 proposed to perform a gradual dose reduction for Mirtazapine 15 milligrams (mg) daily, and 07/2019 proposed to perform a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and staff interview the facility failed to perform gradual dose reduction with anti-psychotic medications. This affected one (#33) out of five residents reviewed for unnecessary medications. Facility census was 54. Findings include: Medical record review revealed Resident #33 was admitted on [DATE] with diagnosis including dementia, coronary artery disease, asthma, osteoarthritis, depression, benign prostatic hyperplasia, anxiety, hypothermia, malnutrition, pain, anemia, hypertension, mood disorder, acute respiratory failure, and hypoxia, gastro-esophageal reflux disease. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #33 has severe cognitive deficits, requires extensive assistance with activities of daily living, and is always incontinent of bowel and bladder. Review of Pharmacy Monthly Reviews dated 06/2019 proposed to perform a gradual dose reduction for Mirtazapine 15 milligrams (mg) daily, and 07/2019 proposed to perform a gradual dose…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-11-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 — the official record, unedited, may be distressing
Based on observation, staff interview, and policy review, the facility failed to remove expired insulin from medication cart. This had to the potential to affect one (#32) out of one resident identified by the facility as receiving insulin on the fourth floor east hall medication cart. Facility census was 54. Findings include: Observations of medication storage on the fourth floor east hall medication cart on 11/25/19 at 1:10 P.M. revealed a Novolog insulin pen opened on 10/22/19 indicating insulin was expired by approximately six days. Interview on 11/25/19 at 1:16 P.M. with Registered Nurse #11 verified that the insulin should have been removed from the medication cart on 11/19/19 due to Novolog was only good for 28 days. The facility confirmed Resident #32 is the only resident on the fourth floor east hall who receives insulin. Review of the Storage of Medication Policy (not dated) revealed all expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining.
- Potential for harm · D2019-11-26 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and staff interview, the facility failed to have accurate physician's orders documented in the resident's medical record. This affected one (#22) of 18 residents reviewed for physician's orders. The facility census was 54. Findings include: Review of Resident #22's medical records revealed an admission dated of 12/12/18 with diagnosis including dementia, depression, schizoaffective disorder, bipolar type, bipolar disorder, hypertension, anxiety, frontotemporal dementia, mood disorder, malignant neoplasm of right female breast, atherosclerotic heart disease of native coronary artery, and symbolic dysfunctions. Review of resident's physician's orders revealed the following orders all initiated on 12/13/18: May go on leave of absence (LOA) supervised., May go on LOA unsupervised., May go out on LOA with meds., and May not go out on LOA. Interview on 11/25/19 at 9:38 A.M. Licensed Practical Nurse (LPN) #13 verified Resident #22 had conflicting orders regarding whether or not the resident may leave the facility. She stated that the facility used standing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-26 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
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 resident's call lights were functioning in a manner to allow the resident to call for staff assistance. This affected one (#16) out of the 24 residents reviewed for call light functioning. The facility census was 54. Findings include: Record review revealed Resident #16 was admitted to the facility on [DATE] with the following diagnoses; other obsessive compulsive disorder, anxiety disorder, chronic obstructive pulmonary disease, schizoaffective disorder, hypertensive heart and chronic kidney disease without heart failure, muscle weakness, major depressive disorder, psychosis and gastro esophageal reflux disease. Review of Resident #16's significant change Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and require extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #16 also required supervision with eating. Observation of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to HEALTH CARE FACILITY MANAGEMENT, LLC — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.8 | +1.2 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 2 of 5 | 2.6 | -0.6 vs chain |
| Quality measures | 5 of 5 | 5.0 | ≈ chain avg |
The other 4 homes this chain runs (chain average 3.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CT OPERATIONS HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/01/2019 |
| COBALT I IRREVOCABLE TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 09/01/2019 |
| COBALT II IRREVOCABLE TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 09/01/2019 |
| COBALT III IRREVOCABLE TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 09/01/2019 |
| COBALT IV IRREVOCABLE TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 09/01/2019 |
| CT HEALTHCARE HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 09/01/2019 |
| MINORITY REPORT LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 09/01/2019 |
| TOLEDO HC HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 09/01/2019 |
| MARINO, PETER | Individual | CORPORATE OFFICER | — | since 09/01/2019 |
| ROMEO, DOMINIC | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2023 |
| TRANQUILLO, DEBORAH | Individual | CORPORATE OFFICER | — | since 09/01/2019 |
| PARKWAY MGT CO LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/10/2025 |
| GROVES, DONNA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/14/2023 |
| MATHIS, STACY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/05/2021 |
| SEROTA, GRETCHEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2021 |
| ODENTHAL, RICHARD | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/10/2025 |
| PRESERVE RE HOLDINGS, LLC | Organization | ADP OF THE SNF | — | since 09/01/2019 |
CMS files one row per role, so the 28 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.
10 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.
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 $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365925. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-17, 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.