Chamberlin Healthcare Center
3889 East Galbraith Road, Cincinnati, OH 45236 · For profit - Limited Liability company · 162 certified beds · (513) 793-5222 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2023
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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) | 3 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 1 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.9% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 1.2% | 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 | 0.2% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 15.5% | 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 | 3.1% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 3.2% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 17.2% | 25.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 95.1% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.4% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.4% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.4% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.9% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 47.5% | 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 0.10 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% 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 | 11.4%CMS range 6.7–18.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.5%CMS range 5.1–17.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.32 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 162 beds and averages 154.2 residents a day — about 95% occupied, or roughly 8 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.96 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 3.09 hrs/resident/day on weekends vs 3.30 on weekdays — 7% thinner on weekends. RN hours go from 0.45 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 52% 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.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · F2026-05-14 · 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 observation, staff interview, and review of the facility policy, the facility failed to ensure food was stored, served, and prepared in a safe and sanitary manner. This had the potential to affect all of the residents residing in the facility except for one resident that the facility identified with an order for nothing by mouth. The facility census was 157 residents. Findings include: 1.Observation of dry storage on 05/11/26 at 9:39 A.M. revealed the following open and undated items: open bags of gravy mix, spaghetti noodles, macaroni noodles, two containers of peanut butter Interview 5/11/26 at 9:40 A.M. with Dietary Manager (DM) #250 verified the open and undated items. 2. Observation on 05/11/26 at 9:46 A.M. revealed there was an open container of mashed potato mix without a lid being stored on top of the steamer. Interview on 05/11/26 at 9:46 A.M.with DM #250 verifed that the mashed potato mix should be covered when stored. 3. Observation on 05/11/26 at 9:47 A.M. revealed a bowl of hard boiled eggs was being stored at room temperature on top of the steamer. Interview…
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 · D2026-05-14 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure privacy and dignity during medication administration. This affected one (Resident #138) of three residents reviewed for dignity. The facility census was 157 residents. Findings include: Review of the medical record for Resident #138 revealed an admission date of 10/09/14 with diagnoses including chronic kidney disease, aphasia following unspecified cerebrovascular disease, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the Minimum Data Set (MDS) assessment for Resident #138 dated 05/03/26 revealed the resident had severely impaired cognition and was dependent on staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #138 revealed an order dated 05/09/26 Lantus insulin 15 units per subcutaneous injection every morning and at bedtime for diabetes. Observation on 5/12/26 at 8:51 A.M. revealed Licensed Practical Nurse (LPN) #149 administered a Lantus insulin injection to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, resident interview, observation, staff interview, and policy review, the facility failed to serve palatable meals at the preferred temperature. This affected one (Resident #9) and had the potential to affect all residents who received food from the kitchen. The facility identified one resident with orders for nothing by mouth. The facility census was 157 residents. Findings include: Review of the medical record for Resident #9 revealed an admission date of 10/05/24 with a diagnosis of degeneration of nervous system due to alcohol. Review of the Minimum Data Set assessment for Resident #9 dated 02/28/26 revealed the resident was cognitively intact. Interview on 05/11/26 at 2:03 P.M. with Resident #9 confirmed the food was served cold and did not taste good. Observation 05/13/26 at 2:28 P.M. of the test tray revealed the mashed potatoes were 109 degrees Fahrenheit (F) and the roast beef was 99 degrees F. The potatoes were bland in flavor and the roast beef was cold. Interview on 05/13/26 at 2:29 P.M. with the Dietary Manager (DM) verified the potatoes…
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 before2026-05-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure enhanced barrier precautions (EBP) were followed. This affected one (Resident #8) of three residents reviewed for infection control. The facility census was 157 residents.Findings include: Review of the medical record for Resident #8 revealed an admission date of 09/23/24 with diagnoses including Parkinson's disease, epilepsy, bipolar disease, chronic kidney disease, and obstructive and reflux uropathy. Review of the care plan for Resident #8 dated 10/09/24 revealed the resident requires EBP for indwelling catheter. Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 02/26/26 revealed the resident had moderately impaired cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #8 revealed an order dated 04/22/26 for EBP related to the presence of an indwelling catheter. Observation of Resident #8's room on 05/13/26 at 8:43 A.M. revealed there was no EBP sign on the resident's door nor 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 · D2024-07-25 · 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 and staff interview, the facility failed to ensure resident's code status matched in the hard (paper) and electronic chart. This affected two (#76 and #139) residents of 34 residents reviewed for advanced directives. The facility census was 146. Findings include: Review of the Resident #76's chart revealed Resident #76 admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, weakness, repeated falls, gastrostomy status, and hypothyroidism. Review of Resident #76's significant change Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was not assessed and Resident #76 required maximal assistance with upper body dressing, rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair transfers, and walking ten feet. Resident #76 was dependent with oral hygiene,…
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 · D2024-07-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview, nursing home bill of rights review, and policy review, the facility failed to provide a clean and home like environment. This affected three (#22, #70, and #446) of 29 residents reviewed for environment. The facility census was 146. Findings Included: 1. Review of the medical record for Resident #22 revealed an admission date of 04/21/23. Diagnoses included chronic obstructive pulmonary disease, type two diabetes, Alzheimer's disease, dementia, and psychosis not due to a substance or physiological condition. Review of MDS dated [DATE] revealed Resident #22 was severely cognitively impaired. Resident #22 required supervision for eating. Resident #22 was dependent for oral hygiene, toileting, dressing upper and lower clothing, personal hygiene, bathing, and transfers. Review of plan of care dated 05/22/24 revealed resident was at risk for falls and to apply the Dycem to wheelchair, assess risk for falls on admission, bed in lowest…
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 · D2024-07-25 · 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 record review and staff interview, the facility failed to correctly code the Minimum Data Set (MDS) assessment for the proper discharge location. This affected one (#144) of three residents reviewed for discharge. The census was 146. Findings include: Review of Resident #144's medical record revealed an admission date of 02/16/24 and discharge date of 05/03/24, with diagnoses including: cellulitis of right lower leg, schizophrenia, and schizoaffective disorder. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #144 was cognitively intact and required assistance for mobility, she was having hallucinations and delusions, and verbal behaviors. Review of care plan revealed a discharge plan to home or another facility. Review of progress note date 05/03/24 at 12:44 P.M., revealed Resident #144 signed out of facility against medical advice (AMA), it was explained to resident that by leaving against advice she cannot take medications with her and she releases the facility from 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 · D2024-07-25 · 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 record review, staff interview, and policy review, the facility failed to develop a care plan for a resident with vision impairment. This affected one (#52) of 29 residents reviewed for care planning. The facility census was 146. Findings include: Review of the Resident #52's medical record revealed an admission date of 03/17/23, with diagnoses including type two diabetes mellitus with diabetic polyneuropathy, atherosclerotic heart disease of native coronary artery without angina pectoris, pure hypercholesterolemia, anxiety disorder, spinal stenosis, other intervertebral disc degeneration lumbar region, obsession compulsive disorder, depression, other chronic pain, insomnia, hypertension, chronic pain and tobacco use. Review of Resident #52's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #52 required supervision with eating, oral hygiene, toileting, personal hygiene, lying to sitting, sitting to standing, chair transfers, toilet…
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 · D2024-07-25 · 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 record review, staff interview, and policy review, the facility failed to ensure care plans were updated timely with fall interventions. This affected one (#139) of five residents reviewed for falls. The facility census was 146. Findings include: Review of the medical record for Resident #139 revealed an admission date of 05/03/24. Diagnoses included dementia, chronic obstructive pulmonary disease, unspecified severe protein-calorie malnutrition, hyperlipidemia, chronic atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, anemia, major depressive disorder, chronic kidney disease, aphasia, and unspecified psychosis not due to a substance or known physiological condition. Review of the facility assessment titled Fall Risk Observation Tool, dated 05/11/24, revealed Resident #139 was at risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #139 had severely impaired cognition. Resident #139 was assessed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-25 · 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, medical record review, resident interview, staff interview, and review of policies, the facility failed to provide safe storage for cigarettes and alcohol. This affected one (#128) of one resident reviewed for smoking. The facility failed to provide care planned fall interventions for residents at risk for falls. This affected two (#22, #103) of three residents reviewed for falls. The facility census was 146. Findings included: 1. Review of medical record for Resident #22 revealed an admission date 04/21/23. Diagnoses included chronic obstructive pulmonary disease, type two diabetes, Alzheimer's disease, dementia, and psychosis not due to a substance or physiological condition. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was assessed as having severe cognitive impairment. Resident #22 required supervision for eating. Resident #22 was dependent for oral hygiene, toileting, dressing upper and lower clothing, personal hygiene, bathing, and transfers. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · D2024-07-25 · 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 medical record review, observation, staff interviews, and policy review, the facility failed to provide timely incontinence care for a resident dependent on staff for care. This affected one (#51) of one resident reviewed for incontinence care. The facility census was 146. Findings included: Review of medical record for Resident #51 revealed an admission date of 06/21/24. Diagnoses included Alzheimer's disease, anxiety disorder, dementia, and major depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was severely cognitively impaired. Resident #51 required substantial maximal assistance for personal hygiene, bathing, transfers, lower body, toileting, and transfers. Resident #51 required partial assistance for dressing upper body. Review of plan of care dated 07/04/24 revealed that Resident #51 was at risk for incontinent of urine. Interventions were to apply barrier creams as needed, check resident for incontinence, and observe for signs and symptoms of urinary…
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 before2024-07-25 · 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 medical record, observation, staff interview, resident interview, and review of policies, the facility failed to ensure medications were provided with an open date when being utilized to ensure medications were not expired. This affected two (#13 and #127) residents observed during medication storage. The facility failed to ensure medications were not left at the bedside and were consumed when administered. This affected one (#117) randomly observed resident. The facility census was 146. Findings include: 1. Observation on [DATE] at 9:30 A.M., of the medication cart revealed Resident #13 had open bottle Keppra 100 mg/milliliter liquid and had no open date on bottle. Resident #13 also had an open bottle of Felbamate 600 mg/5 ml liquid with no open date on the bottle. Interview on [DATE] at 9:45 A.M., with Director of Nursing (DON) verified the nurse was to place a date on the medication when opened for both Keppra and Felbamate bottles. 2. Observation on [DATE] at 9:50 A.M., of the medication cart with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record, observation, resident interview, staff interview and policy reviews, the facility failed to ensure the proper transmission-based precautions were provided for a resident per physician orders. This affected one (#109) of one resident reviewed for infection control. The facility census was 146. Findings include: Review of medical record for Resident #109 revealed an admission date 03/14/24. Diagnoses included chronic pulmonary disease, severe combined immunodeficiency with low T and B cells, and psychotic disorder with delusions. Review of physician order for Resident #109 dated 07/18/24 revealed an order for contact precautions every morning and bedtime due to Shingles. Resident #109 was allowed to come out of the room if rash was covered. Review of physician order for Resident #109 dated 07/20/24 revealed an order for the antibiotic Valtrex oral one gram to give one tablet twice a day for seven days for Shingles. Observation on 07/23/24 at 4:01 P.M., revealed Resident #109 had enhanced barrier precautions sign hanging on her door. Resident #109 was sitting…
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 · D2024-07-25 · 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, resident interview, and staff interviews, the facility failed to ensure call lights were accessible to residents while in bed. This affected three (#51, #143, and #446) of three residents reviewed for call lights. The facility census was 146. Findings included: 1. Review of medical record for Resident #51 revealed an admission date of 06/21/24. Diagnoses included Alzheimer's disease, anxiety disorder, dementia, and major depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was severely cognitively impaired. Resident #51 required supervision with meals, required partial and moderate assistance with oral care, substantial maximal assistance for personal hygiene, bathing, transfers, lower body, and transfers. Review of plan of care dated 06/21/24 revealed Resident #51 was at risk for falls related to injury related to decreased cognition and safety. Interventions included assess for risk for falls, educate resident or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-26 · 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 record review, review of facility Self-Reported Incidents (SRIs) staff interviews, review of witness statements, review of employee personnel file, and review of facility policy, the facility failed to prevent an incident of resident-to-resident abuse. This affected one (#100) of three residents reviewed for abuse. The facility census was 137. Findings include: Review of the medical record for Resident #100 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, cocaine dependence, constipation, psychoactive substance abuse, pseudobulbar affect, anoxic brain damage, impulsiveness, ataxia, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 07/14/23 for Resident #100 revealed the resident had severely impaired cognition. Resident #100 required extensive assistance from staff with transfers. Review of the September 2023 nursing notes for Resident #100 revealed no documentation regarding the resident being involved 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 · D2023-10-26 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility Self-Reported Incidents (SRIs) staff interviews, review of witness statements, review of employee personnel file, and review of facility policy, the facility failed to ensure the facility's abuse policy was implemented when two separate incidents of resident-to-resident physical abuse occurred. This affected three (#108, #100 and #115) out of three residents reviewed for abuse. The facility census was 137. Findings include: Review of the medical record for Resident #108 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Dementia, osteoarthritis, alcohol dependence, essential primary hypertension. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #108 dated 09/13/23, revealed the resident had mild cognitive impairment. Resident #108 required extensive assistance from staff with bed mobility and transfers. Review of the nurse's progress notes for Resident #108 dated 09/22/23, revealed the resident was going toward the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-26 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of facility's self-reported incidents (SRIs), review of witness statements, and review of facility policy review, the facility failed to timely report allegations of resident-to-resident physical abuse to the state agency. This affected three (#108, #100 and #115) out of three residents reviewed for abuse. The facility census was 137. Findings include: Review of the medical record for Resident #108 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Dementia, osteoarthritis, alcohol dependence, essential primary hypertension. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #108 dated 09/13/23, revealed the resident had mild cognitive impairment. Resident #108 required extensive assistance from staff with bed mobility and transfers. Review of the nurse's progress notes for Resident #108 dated 09/22/23, revealed the resident was going toward the dining room with her walker when Resident #115 grabbed her. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-09-08 · tag F0553 — failed to let residents help plan their care — patternAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were invited care plan conference meetings to provide input to their plan of care. This affected four (Residents #19, #24, #53, and #216) of six residents reviewed for participation in care planning. The facility census was 74. Findings include: Review of the medical record revealed Resident #19 was admitted on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/31/21, revealed the resident had no impaired cognition for decisions. Resident #19's medical record contained no documentation pertaining to care conferences. During interview on 08/24/21 at 10:53 A.M., Resident #19 stated she had attended a care plan meeting on admission but had not been to one since. 2. Review of the medical record revealed Resident #24 was admitted on [DATE]. Review of the quarterly MDS assessment, dated 07/09/21, revealed the resident had no impaired cognition for decisions. Resident #24's medical record contained no documentation…
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 before2021-09-08 · 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 record review, observation, interview and policy review, the facility failed to ensure cleaning chemicals were stored in a locked area on the memory care unit and failed to ensure window locks on the memory care unit on the second floor were operational to prevent the windows being completely opened. This had the potential to affect 20 confused and independently ambulatory residents ( Residents #3, #7, #10, #12, #14, #16, #17, #23, #31, #34, #35, #39, #41, #44, #45, #55, #61, #64, #116 and #166 ) identified by the facility. The facility census was 74. Findings include: 1. During observation on 08/23/21 at 12:00 P.M. of biohazard room in the women's secured memory care unit was unlocked. The room contained four full red sharp containers on a countertop. One box identified as biohazard material was partially full of red biohazard bags. Under the counter was a full spray bottle of disinfectant with warning label to keep out of reach of children. During observation on 08/23/21 at 12:04 P.M., the housekeeping closet door was unlocked with a gallon bottle of germicidal…
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 · D2021-09-08 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure a motorized wheelchair was repaired in a timely manner. This affected one resident (Resident #19) of one resident reviewed for accommodation of needs. Census was 74. Findings include: Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included but not limited to chronic obstructive pulmonary disease, shortness of breath, diabetes mellitus due to underlying condition with hypoglycemia without coma, type two diabetes, mood disorder, periodic paralysis, hypertension, unspecified glaucoma stage, pruritus, chronic pain, and sensorineural hearing loss bilateral. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/31/21, revealed the resident was cognitively intact for decisions, having clear speech, understand others, others understand him and total dependent with activities of daily living with two persons for physical assist. Resident #19 has impairment on left side of body and uses 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 · D2021-09-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews and policy, the facility failed to provide ensure assistance to dependent residents on staff for grooming. This affected one resident (#57) of four reviewed for personal care. The facility census was 74. Findings include: Review of the medical record revealed Resident #57 was admitted on [DATE]. Diagnoses included but not limited to gatro-esophageal reflux disease without esophagitis, hypertension, atrial fibrillation, autistic disorder, altered mental status, abnormalities of gait and mobility, sensorineural hearing loss, bilateral, unspecified lack of expected normal physiological development in childhood, retention of urine, hyperlipidemia, cystostomy, obstructive and reflux uropathy, major depressive disorder, and overactive bladder. Review quarterly Minimum Data Set (MDS) dated [DATE] for modification of admission revealed Resident #57 had severe cognitive impairment and required one-person physical assist for bathing and personal hygiene. 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 · D2021-09-08 · 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
Based on record review, observation, interview and policy review, the facility failed to assess and report fingernail abnormality. This affected one (Resident #28) of three residents reviewed for nail care. The facility census was 74. Findings include: Review of medical record for Resident #28 revealed an admission date on 09/04/20 with diagnoses including history of Covid-19, dementia with behaviors, hypertension, major depressive disorder, urinary tract infection, moderate protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/12/21, revealed the resident had a severely impaired cognition. Review of the plan of care for Resident #28 dated 04/30/21 revealed the resident has an activities of daily living (ADL) self care performance deficit related to dementia. Interventions include resident requires extensive assist for bathing, bed mobility, dressing and assist with personal hygiene and monitor document report as needed an changes, or reasons for self care deficit, expected course and decline in functioning. Review of the weekly skin…
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 · D2021-09-08 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, observation and interview, the facility failed to employ a full time Director of Nursing (DON). This had the potential to affect all residents residing in the facility. The facility census was 66. Review of the facility staffing schedules for 08/16/21 through 08/23/21 revealed the DON was scheduled Monday through Friday. Observations from 08/23/21 through 08/26/21 at random intervals revealed the DON was across the street at the facility's sister facility. The DON would come back and forth as needed. Interview with the DON on 08/25/21 at 11:20 am revealed she was the DON for this facility and the facility next door. She verified she was the only DON working at both facilities. She stated she worked approximately 50 hours per week, 20 hours in the facility next door and 30 hours in the other facility. She stated she was sometimes working on things for this facility while in the other one but was not physically here.
- Potential for harm · D2021-09-08 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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, interview, observation and policy review, the facility failed to adequately monitor medications for adverse side effects or identify the behaviors targeted for treatment. This affected two (Residents #59 and #168) of four residents reviewed for psychoactive medications. The facility census was 66. Findings include: 1. Medical record review revealed Resident #5 was admitted on [DATE] with diagnoses including history of Covid-19, Alzheimer's disease, altered mental status, major depressive disorder, heart failure, kidney failure, falls, and delusional disorders. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/04/21, revealed the resident was cognitively impaired. The resident received an antipsychotic and an antidepressant daily during the assessment period. Review of the plan of care for Resident #59 dated 03/28/19 revealed resident has the potential for side effects of psychotropic medication usage. Interventions include administer medications as ordered and monitor…
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 before2021-09-08 · 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
Based on observation, interview and policy review, the facility failed to ensure expired medications were disposed of timely. This had the potential to affect 41 residents residing on the Buckeye Lane and Tower Two units. The facility census was 74. Findings include: Observation on 08/26/21 at 10:10 A.M. of the Buckeye unit medication storage room revealed an opened and undated multi use vial of tuberculin purified protein with and expiration date of 02/22. Interview with Director of Nursing at the time of the observation verified the vial should have been dated when it was opened. Observation on 08/26/21 at 10:30 A.M. of Tower Two medication storage room revealed a bottle of vitamin D 1000 units opened with an expiration date of 03/2021, a opened bottle of oyster shell calcium 500 mg with an expiration date of 08/2020, an opened bottle of stool softener 100 mg with an expiration date of 01/2021, a plastic bag with promethazine rectal suppositories with an expiration date of 01/21, and eleven individual vials of prefilled influenza vaccines single dose with an expiration date 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 COMMUNICARE HEALTH — 110 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 | 3.2 | +1.8 vs chain |
| Health inspection | 4 of 5 | 2.7 | +1.3 vs chain |
| Staffing | 3 of 5 | 2.6 | +0.4 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 109 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 109; lowest-rated first.
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 |
|---|---|---|---|---|
| BUCKEYE OP CO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 07/01/2021 |
| BUCKEYE HEALTHCARE HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 07/01/2021 |
| OMG MSTR LSCO, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 07/01/2021 |
| ROMEO, DOMINIC | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2023 |
| STOLTZ, CHARLES | Individual | CORPORATE OFFICER | — | since 07/01/2021 |
| WILHEIM, RONALD | Individual | CORPORATE OFFICER | — | since 07/01/2021 |
| NEAR KNOLL MGT CO., LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/06/2025 |
| GROVES, DONNA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/14/2023 |
| KAREV, MILLA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2021 |
| SHERMAN, SIERRA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/10/2025 |
| C.R. STOLTZ FAMILY INVESTMENT COMPANY INC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| C.R. STOLTZ IRREVOCABLE TRUST | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| HEALTH CARE HOLDINGS, LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| I. ROSEDALE FAMILY INVESTMENT COMPANY INC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| I. ROSEDALE IRREVOCABLE TRUST | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| R.S. WILHEIM IRREVOCABLE TRUST | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| RONALD S WILHEIM 2012 SPOUSAL TRUST | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| ROSEDALE FAMILY INVESTMENT COMPANY, INC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| RRW, LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| S.L. ROSEDALE IRREVOCABLE TRUST | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| WILHEIM FAMILY INVESTMENT COMPANY, INC. | Organization | ADP OF THE SNF | — | since 07/01/2021 |
CMS files one row per role, so the 28 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted.
15 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 76% 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 $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 13% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 365734. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, 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 →
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