Burlington House Rehab & Alzheimer's Care Center
2222 Springdale Road, Cincinnati, OH 45231 · For profit - Limited Liability company · 122 certified beds · (513) 851-7888 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- 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 last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 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
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 1 to 3 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 | 2.8% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 8.5% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 92.0% | 30.1% | 6.5% | worse 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 | 9.6% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 3.9% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 13.2% | 25.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 63.2% | 94.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 2.6% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 29.1% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.9% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 4.5% | 1.2% | 1.4% | 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 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 122 beds and averages 101.9 residents a day — about 84% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.26 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.78 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 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 2.94 hrs/resident/day on weekends vs 3.39 on weekdays — 13% thinner on weekends. RN hours go from 0.80 to 0.74 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%. 1 administrator has left in the past year.
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · Jcited before2023-05-08 · 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 medical record review, observations, staff interview, review of witness statements, review of the police report, review of information from Google Maps, review of a weather report, review of the facility investigative files, review of in-service education, and policy review, the facility failed to complete thorough investigations following resident elopements to prevent additional elopements from occurring. Additionally, the facility failed to update residents' elopement assessments and care plans following elopements. Lastly, the facility failed to identify like-residents at risk for elopement to ensure appropriate interventions were in place to potentially prevent the same actions, situations, and/or practices from occurring in the future. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] at an unknown time when Resident #306, who resided on the west hall, exited the facility's secured unit on the south hall through a thirty…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2019-11-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 provide nutritional supplementation as recommended by the Registered and Licensed Dietitian (RD, LD), and ordered by the physician, to improve the nutritional status of a resident identified with significant weight loss. This resulted in actual harm when Resident #36 was identified as having a 7.99 percent (%) significant weight loss in one month and did not receive nutritional interventions as ordered. In addition, the facility failed to provide nutritional interventions as ordered and identified on a second resident's (#20) care plan that placed the resident at risk for more than minimal harm. This affected two (#36 and #20) of seven residents reviewed for Nutrition. The facility census was 94. Findings include: 1. Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including fracture of the left femur, Alzheimer's disease, hypertensive heart disease, chronic kidney…
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 before2026-03-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, review of Safety Data Sheets (SDS), and review of the facility policy, the facility failed to ensure hazardous chemicals were properly stored. This had the potential to affect 28 independently mobile and cognitively impaired residents residing on the west and south units. The facility census was 106 residents. Findings include:1. Observation on 03/17/26 at 9:21 A.M. revealed there was an open container of wipes labeled Sani-Cloth Plus Germicidal Disposable Cloth located on the floor under a desk at a nurses' station on the west unit. The label on the wipes indicated they should be kept out of reach of children and could be hazardous to humans and domestic animals. There was also an open container of wipes labeled Sani-Hands Instant Sanitizing Wipes. The label on the wipes indicated they should be kept out of reach of children unless under adult supervision and to obtain medical help or contact a poison center immediately if swallowed.Interview on 03/17/26 at 9:29 A.M. with the Executive Director (ED) confirmed the open containers of wipes on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-12 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and closed and open record reviews and facility policy review, the facility failed to ensure a resident was free from sexual abuse. This affected one resident (Resident #81) of one resident reviewed for sexual abuse. The facility total census was 97. Findings included: Closed record review for Resident #81 revealed the resident was admitted to the facility on [DATE] and discharged on 04/23/25 to home. Diagnoses for Resident #81 included Alzheimer ' s, dementia, heart disease, depressive disorder, and psychosis. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE], revealed the resident had severely impaired cognition and required partial assistance with toileting and supervision with ambulation. There were no functional impairments. The resident resided on the memory secured unit in room [ROOM NUMBER]. The resident had a guardian. Resident #81 had an emergency room visit on 03/30/25 and returned on 03/30/25. Record review of Resident Perpetrator, (RP) #11 revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-19 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake 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 and staff the facility failed to ensure a clean and sanitary environment in resident bathrooms. This affected two (Residents #25 and #27) of three residents reviewed for physical environment. The facility census was 100 residents. Findings include: Observation on 09/16/24 at 9:12 A.M. with State Tested Nurse Aide (STNA) #111 revealed a ceiling tile in Resident #25 and #27's bathroom had a large ring of discoloration of an unknown dark substance. Interview on 09/16/24 at 9:13 A.M. with STNA #111 confirmed the discolored ceiling tile in Resident #25 and #27's bathroom had been that way for a least a month and had occurred following a water leak. Observation on 09/17/24 at 11:00 A.M. revealed the ceiling tile in Resident #25 and #27's bathroom still had a large ring of discoloration of an unknown dark substance. Interview with on 09/17/24 at 11:00 A.M. with Maintenance Technician (MT) #81 confirmed the ceiling tile in Resident #25 and #27's bathroom was discolored, and he was going to treat the area with a commercial mold and mildew spray. This deficiency…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 record review, observations, staff interviews, and review of facility policy, the facility failed to provide timely incontinence care. This affected one resident (#04) out of three reviewed for incontinence care. The facility census was 98. Findings Included: Review of medical record for Resident #04 was admitted [DATE]. Diagnosis included Alzheimer's disease, dementia, epilepsy, hemiplegia, and hemiparesis. Review of the Bowel assessment dated [DATE] revealed Resident #04 was incontinent of bowel and required to be checked and changed every two hours. Review of the Urinary Incontinence assessment dated [DATE] revealed Resident #04 was incontinent with multiple episodes daily. Resident #04 wore an incontinent brief and was required to be checked and changed every two hours. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #04 had a Brief Interview of Mental Status (BIMS) of 03 which indicated she was severely cognitively impaired. Resident #04 was dependent on staff for all…
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 before2024-05-02 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on [NAME] record review, observations, staff interviews, review of facility documents and policy review, the facility failed to provide resident's with a clean and sanitary environment. This affected four (#06, #10, #48, #80) out of four residents reviewed for the physical environment. The facility census was 99. Findings include: 1. Record review for Resident #06 revealed he was admitted to the facility on [DATE]. His diagnoses included, diabetes mellitus (DM)2, lymphedema, essential primary hypertension, anxiety disorder, adjustment disorder, heart failure, major depressive disorder, and chronic kidney disease stage 2. Review of the most recent Minimum Data Set (MDS) assessment, dated 03/28/24, revealed Resident #06 had severely impaired cognition. Further review for the MDS assessment revealed he required maximum assist with toileting and bathing. Interview and observation on 04/30/24 at 2:30 P.M. with the housekeeper (HK) #90 confirmed she had cleaned Resident #06's room at an earlier time on 04/30/24.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-02 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 a facility self-reported incident (SRI), observations, staff interviews, review of personnel files and policy review, the facility failed to ensure a resident was free from physical abuse. This affected one (#15) out of two residents reviewed for abuse. The facility census was 99. Findings include: Record review for Resident #15 revealed the resident was admitted to the facility on [DATE]. Her diagnoses included, hydrocephalus, osteoarthritis, schizo affective disorder, hypothyroidism, hyperlipidemia, major depressive disorder, anxiety disorder, dementia, and essential primary hypertension. Review of the most recent Minimum Data Set (MDS), dated [DATE], revealed Resident #15 had severe cognitive impairment. Further review of the MDS assessment for Resident #15 revealed she required maximum assistance from staff with toileting, bathing, and personal hygiene and was dependent on staff for medication management. Review of Resident #15's behavior care plan initiated on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-02 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 ensure a valid Preadmission Screening and Resident Review (PASARR) was completed upon admission to the facility. This affected one (#06) out of one resident reviewed for PASARR. The facility census was 99. Findings Include: Record review for Resident #06 revealed he was admitted to the facility on [DATE]. His diagnoses included, diabetes mellitus (DM)2, lymphedema, essential primary hypertension, anxiety disorder, post traumatic stress disorder (PTSD), adjustment disorder, heart failure, major depressive disorder, and chronic kidney disease stage 2. Review of the most recent Minimum Data Set (MDS) assessment, dated 03/13/24, revealed Resident #06 had severely impaired cognition. Further review for the MDS assessment revealed he required maximum assist with toileting and bathing. Review of the PASARR Review for Resident #06 dated 03/13/24 revealed the facility failed to identify Resident #06's mental health diagnoses of major depressive disorder.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 interviews and policy review, the facility failed to ensure residents with compromised nutrition status were weighed weekly as ordered. This affected three (#70, #33, and #85) of nine residents reviewed for nutrition. The facility census was 99. Findings include: 1. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including hyperlipidemia, unspecified obesity, major depressive disorder, and generalized anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment completed on 04/11/2024 revealed Resident #70 had severely impaired cognition, had no behaviors, did not wander, and did not reject care. Review of the care plan dated 11/04/2022 revealed Resident #70 had potential for altered nutrition, had weight loss, needs for supplementation, and had inconsistent meal intakes. Interventions included identify resident preferences notify provider/family of unplanned weight loss, obtain daily weights as needed, offer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-02 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and review of medication information, the facility failed to ensure residents were free from unnecessary psychotropic medications when the facility administered antipsychotic medications without an adequate indication of use. This affected two (#66 and #349) of five residents reviewed for unnecessary medications. The facility census was 99. Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 01/24/24 with diagnoses of Alzheimer's Disease, dementia with other behavioral disturbance, unspecified psychosis not due to a substance or known physiological condition, and malignant neoplasm of unspecified site of right female breast. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 is cognitively impaired and frequently incontinent of bowel and bladder. Resident #66 has no range of motion impairment in upper and lower extremities, requires touch assistance with eating, oral hygiene, toileting, bathing,…
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 before2023-05-08 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of manufacturer recommendations, and policy review, the facility failed to ensure expired medications were removed from the medication carts. This affected two medication rooms out of two observed, and two medication carts out of three carts observed for expired medications. This had the potential to affect all residents who reside in the facility. The facility census was 101. Findings include: Observation on 04/24/23 at 1:22 P.M. of the west unit cart one with Licensed Practical Nurse (LPN) #315 revealed there was one bottle of stool softener that expired on 10/2022, a bottle of calcium carbonate (a supplement) expired on 11/2022, and a bottle of senna plus (a laxative) that expired on 03/2023. Observation on 04/24/23 at 1:23 P.M. with LPN #315 revealed three vials of tuberculin serum were opened and undated. Interview on 04/24/23 at the time of the observation with LPN #315 verified the expired medications. Observation on 04/24/23 at 1:25 P.M. with LPN #426 of the Mount…
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 19 citations
- Potential for harm · F2023-05-08 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observations, and staff interviews, the facility failed to ensure dietary staff were competent to fulfill their responsibilities. This had the potential to affect 100 residents who received food from the kitchen. The facility identified one resident (#24) who did not consume any food from the kitchen. The facility census was 101. Findings include: Interview on 04/19/23 at 5:49 P.M. with Culinary Aide #342 revealed he would put his hand in the water from the dishwasher and make an educated guess regarding the temperature. Review of a performance evaluation for Culinary Aide #346 completed on 11/07/22 indicated Culinary Aide #346 had an N for no on the evaluation for testing of parts per million (PPM) for the low temperature dishwasher. Review of a performance evaluation for Culinary Aide #342 completed on 11/08/22 indicated Culinary Aide #342 had an N for no on the evaluation for testing of PPM for the low temperature dishwasher. Interview on 04/20/23 at 3:04 P.M. with [NAME] #372 revealed he was not aware of how to test PPM. Interview on 04/20/23 at 3:13 P.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 · F2023-05-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 record review, observations, staff interviews, review of facility policies, and review of manufacturer guidelines, the facility failed to ensure the refrigerator was functioning properly, foods were covered and dated, and the chemicals used for sanitation were at the recommended level. This had the potential to affect 100 residents who receive food from the kitchen. The facility identified one resident (#24) that did not consume any food from the kitchen. The facility census was 101. Findings include: Observations on 04/17/23 from 6:35 P.M. to 6:45 P.M. of the walk-in refrigerator revealed undated fruit cocktail, undated ricotta cheese, and an uncovered and undated metal container of sausage. The attached walk-in freezer had an undated bag of frozen ravioli, and two plastic sealable bags of an unknown frozen meat that was undated. Interview with Culinary Aide #455 at the time of the observations confirmed the undated and uncovered items in the refrigerator and freezer. Observation on 04/19/23 at 11:59 A.M. of the walk-in refrigerator revealed a metal container of uncovered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-05-08 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, staff interview, and policy review, the facility failed to have a developed Quality Assurance and Performance Improvement Plan (QAPI). This had the potential to affect all 101 residents residing in the facility. Findings include: Review of the facility QAPI program revealed the facility had not developed a QAPI plan for review. Interview on 04/26/23 at 3:21 P.M. with the Administrator confirmed the facility had no documentation of a developed QAPI plan. Review of the facility policy titled QAPI (Quality Assurance Performance Improvement) Plan, reviewed 10/01/22, revealed the QAPI program is ongoing, comprehensive, and encompasses the full range of services offered by the facility.
- Potential for harm · F2023-05-08 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and policy review, the facility failed to develop and implement action plans to improve performance or address concerns as part of their Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all 101 residents residing in the facility. Findings include: Review of the facility QAPI program revealed the facility had no documentation regarding any performance improvement plans initiated to addressed identified concerns. Interview on 04/26/23 at 2:54 P.M. with the Director of Nursing (DON) revealed the facility had addressed concerns such as falls and wound management in their clinical meetings. Interview on 04/26/23 at 3:21 P.M. with the Administrator confirmed the facility had no documentation related to performance improvement activities as part of their QAPI program. Review of the facility policy titled QAPI (Quality Assurance Performance Improvement) Plan, reviewed 10/01/22, revealed that the facility would track, investigate, and monitor adverse events that must be investigated every time they occur,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-05-08 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, staff interview, and policy review, the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly. This had the potential to affect all 101 residents residing in the facility. Findings include: Review of QAPI meeting minutes revealed the facility last conducted a QAPI meeting on 08/30/22. Interview on 04/26/23 at 3:21 P.M. with the Administrator confirmed the last documented QAPI meeting was on 08/30/22. Review of the facility policy titled QAPI (Quality Assurance Performance Improvement) Plan, reviewed 10/01/22, revealed the facility would conduct a QAPI meeting every month where required members would be present, and any trends or other facility data that required review would be addressed.
- Potential for harm · F2023-05-08 · tag F0944 — widespreadConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, staff interview, and policy review, the facility failed to ensure all staff were properly trained on the facility's Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all 101 residents residing in the facility. Findings include: Review of the facility records revealed the facility had no documentation of staff training related to QAPI. Interview on 04/26/23 at 4:19 P.M. with the Administrator confirmed the facility had no evidence of QAPI training records for staff. Review of the facility policy titled QAPI (Quality Assurance Performance Improvement) Plan, reviewed 10/01/22, revealed the facility staff would receive training on QAPI upon hire and annually.
- Potential for harm · D2023-05-08 · 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, family and staff interview, the facility failed to ensure resident assessments were completed accurately. This affected two residents (#59 and #50) of 21 residents reviewed for assessments. The facility census was 101. Findings include: 1. Review of the medical record of Resident #59 revealed an admission date of 11/22/19. The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, dementia, generalized anxiety disorder, hypotension, schizophrenia, and anorexia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had severely impaired cognition. The resident required extensive assistance for bed mobility and transfers. The resident was assessed as receiving tube feeding (K0510B) during the assessment period. Review of Resident #59's medical record revealed no evidence of Resident #59 receiving tube feeding during the assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, observation, and policy review, the facility failed to consistently develop resident centered care plans. This affected two residents (#86 and #91) out of 32 care plans reviewed. The facility census was 101. Findings include: 1. Medical record review revealed Resident #86 was admitted on [DATE] with diagnosis including dementia, hereditary neuropathy, edema, diverticulosis, hypertension, covid, and vitamin B12 deficiency. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #86 had severe cognitive deficits. Review of the care plans revealed Resident #86 had no care plan implemented after an on 11/23/22 and an elopement care plan was not initiated until 04/10/23 after a second elopement. Interview on 04/20/23 at 11:57 A.M., with the Regional Director of Clinical Operations (RDCO) #427 verified the elopement care plan should have been developed on 11/23/22 and the plan was not developed until 04/10/23. Review of the policy titled Plan 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 · Dcited before2023-05-08 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and family interview, and policy review, the facility failed to ensure residents and resident representatives participated in the plan of care. This affected one resident (#86) out of two residents (#38 and #86) reviewed for care conferences. The facility census was 101. Findings include: Medical record review revealed Resident #86 was admitted on [DATE]. Diagnoses included dementia, hereditary neuropathy, edema, diverticulosis, hypertension, covid, and vitamin B12 deficiency. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #86 had severe cognitive deficits. Review of the care conference notes undated revealed no documentation indicating care conferences were offered or completed. Telephone interview on 04/18/23 at 1:27 P.M., with Resident #86's son reported he had not been invited to a care conference in over a year. Interview on 04/24/23 at approximately 4:00 P.M., with the Regional Director of Clinical Operations #427 verified there was no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-08 · tag F0908 — failed to keep essential equipment working — isolatedKeep 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 record review, observation, and resident and staff interview, the facility failed to provide timely servicing of the resident's equipment. This affected one (Resident #04) of 24 residents reviewed for working equipment. The facility census was 101. Findings include: Review of Resident #04's medical record revealed Resident #04 was admitted on [DATE]. Diagnoses included multiple sclerosis, paraplegia, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 had severely impaired cognition and required extensive assistance to total dependence on staff with activities of daily living. An interview on 04/18/23 at 11:51 A.M. with Resident #04 stated he has not been out of his bed in months because the facility took his power wheelchair to fix it and has not brought it back. An observation and interview on 04/19/23 at 1:39 P.M. with Maintenance Director #370 revealed Resident #04's wheelchair was down in storage and not plugged in charging. Maintenance Director #370…
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 · E2019-11-07 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to maintain complete and accurate documentation, including physicians orders, and dietitian recommendations, for four (Resident #5, Resident #20, Resident #36, Resident #297) of 22 residents medical records reviewed. The census was 94. Findings include: 1. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including obstructive and reflux uropathy, overactive bladder, gross hematuria, chronic kidney disease, retention of urine, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance of one person to toilet. Resident #5 was transferred to the hospital on [DATE] for a cystoscopy and Transurethral Resection of the Prostate (TURP). The resident's care plan did not include indwelling catheter care nor urinary elimination. Review of current physician's orders…
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 · D2019-11-07 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and staff interviews, the facility failed to ensure residents were provided care in a dignified manner. This affected two (Resident #7 and #57) of three residents observed for dignity. The total facility census was 94. Findings include: 1. Medical record review revealed Resident #57 was admitted on [DATE]. Diagnoses included Huntington's disease, esophageal obstruction, gastro-esophageal reflux disease with esophagitis, osteoarthritis, major depressive disorder, anxiety disorder, lack of coordination, dementia, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively impaired and was dependent for bed mobility, transfers, toileting, and eating for Activities of Daily Living (ADL). Observation on 11/04/19 at 12:00 P.M., revealed Resident #57 was sitting in the dining room alone facing the wall. Interview on 11/04/19 at 12:18 P.M., revealed State Tested Nursing Assistant (STNA) #32 verified…
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 · D2019-11-07 · 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 record review, staff interview, and policy review, the facility failed to ensure the resident's advance directives were accurate in the medical record. This affected one (Resident #300) of 22 residents reviewed for advanced directives. The facility census was 94. Findings include: Review of Resident #300's medical records revealed an admission date of [DATE]. Review of Resident #300's Minimum Data Set (MDS) assessed revealed the was not completed at the time of review due to his recent admission. Review of Resident #300's progress notes revealed no concerns regarding resident needs for advanced directives from [DATE] to [DATE]. Review of Resident #300's electronic and paper medical records revealed resident to be considered a Full Code and requiring Cardio-Pulmonary Resuscitation (CPR). Observation on [DATE] at 10:14 A.M. revealed Resident #300's hard copy of the signed physician's orders for a Do Not Resuscitate - Comfort Care (DNRCC) order dated [DATE] in another resident's hard chart. Interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-07 · 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 observation, record review, staff interview, and review of facility policy, the facility failed to notify a resident's physician when they experienced a significant unplanned weight loss. This affected one resident (#60) of seven reviewed for Nutrition. The facility census was 94. Findings include: Resident #60 was admitted to the facility in July of 2017 with diagnoses including hypertension, dysphagia, vascular dementia with behavioral disturbance, adult failure to thrive, contracture left shoulder, contracture right hip, Bells' palsy, low back pain, and chronic kidney disease. The facility completed a quarterly minimum data set assessment (MDS 3.0) of Resident #60's cognitive and physical functional status dated 10/01/19. The 10/01/19 assessment identified the resident as having severely impaired cognitive skills, and requiring the physical assistance of at least one staff person for all activities of daily living. The resident was assessed as standing 69 tall and weighing 163 pounds at the time the assessment was completed. Review of Resident #60's physician's orders…
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 · D2019-11-07 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 residents were free from physical restraint imposed to address a behavioral outburst and prevent the resident from accessing his environment. This affected one (Resident #60) of one resident reviewed for restraints. The facility census was 94. Findings include: Resident #60 was admitted to the facility in July of 2017 with diagnoses including hypertension, dysphagia, vascular dementia which behavioral disturbance, adult failure to thrive, contracture left shoulder, contracture right hip, Bells' palsy, low back pain, and chronic kidney disease. Review of Resident #60's current physician orders revealed an order dated 08/29/19 for the resident to use a new tilt-in-space wheel chair with a built in pressure reducing seat and rear anti-tippers, no leg rests to facilitate safe wheel chair mobility and to reduce risk for falls. The facility completed a quarterly minimum data set assessment (MDS 3.0) assessment of Resident #60's cognitive and physical functional status dated 10/01/19. The 10/01/19…
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.
- Potential for harm · D2019-11-07 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide all necessary transfer and discharge notices to three (Resident #1, Resident #5, and Resident #84)of three residents reviewed for transfers and/or discharge. The census was 94. Findings include: 1. Record review revealed Resident #5 admitted to the facility on [DATE] with diagnoses including obstructive and reflux uropathy, overactive bladder, gross hematuria, chronic kidney disease, retention of urine, and benign prostatic hyperplasia with lower urinary tract symptoms. Resident #5 was transferred to the hospital on [DATE] for a cystoscopy and Transurethral Resection of the Prostate (TURP). Review of Resident #5's transfer documentation revealed no information regarding resident rights to appeal the transfer. Review of Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and required extensive assistance of one person to toilet. Interview on 11/06/19 at 3:40 P.M. with Social Services Designee (SSD) #86 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.
- Potential for harm · Dcited before2019-11-07 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop, implement, and update the care plan of one resident (Resident #5) of 22 residents reviewed. The facility census was 94. Findings include: Record review revealed Resident #5 admitted to the facility on [DATE] with diagnosis including obstructive and reflux uropathy, overactive bladder, gross hematuria, chronic kidney disease, retention of urine, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of Resident #5's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance of one person to toilet. Resident #5 was transferred to the hospital on [DATE] for a cystoscopy and Transurethral Resection of the Prostate (TURP). The resident's care plan did not include indwelling catheter care nor urinary elimination. Review of current physician's orders regarding urinary catheter was dated 09/23/19 and indicated the resident's indwelling catheter should…
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 before2019-11-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interviews, the facility failed to ensure fall prevention interventions were in place as ordered. This affected one (Resident #80) of five residents reviewed for falls. Facility census was 94. Findings include: Review of the medical record for Resident #80 revealed an admission date of 04/17/19 with diagnoses including Alzheimer's, diabetes, hypertension, major depressive disorder, stroke, and chronic kidney disease. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated a severe cognitive deficit and the resident required extensive assistance for activities of daily living. Review of Resident #80's current physician orders revealed an order dated 06/11/19 indicated the resident was to wear hipsters at all times and check every shift. A physician order dated 10/21/19 was written for anti-tippers and rollbacks for fall prevention. Review of Resident #80's fall risk care plan revealed an intervention (dated 10/18/19) for anti-tipper and rollbacks to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-11-07 · 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 — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and manufacturer recommendations, the facility failed to ensure medications were labeled when opened. This affected two (Resident #12, and #26) of seven resident's medication storage reviewed during medication administration. The facility census was 94. Findings include: 1. Review of Resident #12's medical record revealed an admission date of 07/26/19 with diagnoses including hypertension, diabetes, depression, osteoporosis, heart and kidney disease. Review of November 2019 physician orders revealed an order for Latanoprost 0.005 percent one drop in eye at bedtime. Medication storage observation on 11/06/19 at 2:05 P.M. revealed a bottle of Latanoprost eye drops labeled for Resident #12. The bottle did not have an opened date. Interview with Licensed Practical Nurse (LPN) #66 verified the Latanoprost bottle was not dated and was the current bottle in use for the resident. She also verified the bottle was delivered to the facility on [DATE]. Review of the manufacturer…
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 | 3 of 5 | 3.8 | -0.8 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 3 of 5 | 2.6 | +0.4 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 |
|---|---|---|---|---|
| PARKWAY MGT CO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/01/2022 |
| MARINO, PETER | Individual | CORPORATE OFFICER | — | since 01/04/2021 |
| TRANQUILLO, DEBORAH | Individual | CORPORATE OFFICER | — | since 09/01/2019 |
| SPRINGDALE MANAGEMENT CO., LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/19/2025 |
| GROVES, DONNA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/14/2023 |
| MOQEETH, SYED | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2021 |
| VANOVER, MARGARET | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/29/2023 |
CMS files one row per role, so the 10 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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 86% 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 $1.0M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 365892. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-05-02, 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.