Cottingham Retirement Community
3995 Cottingham Drive, Cincinnati, OH 45241 · For profit - Limited Liability company · 60 certified beds · (513) 563-3600 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
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — 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 (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 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 2 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 | 2.5% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 9.1% | 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 | 1.0% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 45.1% | 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 | 4.4% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 3.0% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 37.1% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.7% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.4% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.5% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.4% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 25.4% | 75.6% | 79.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.81 | 1.73 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.16 | 1.80 | 1.80 | 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.
44.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.59 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 44.3%CMS range 34.0–57.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.5–14.9 | 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 | 0.0% | 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 | 8.7% | 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 | 8.7%CMS range 4.5–15.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.37 | 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 60 beds and averages 56.7 residents a day — about 94% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.99 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.63 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 2.71 hrs/resident/day on weekends vs 3.10 on weekdays — 13% thinner on weekends. RN hours go from 0.70 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 48% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
19 citations, most serious first. The 11 most serious are shown; the remaining 8 are one tap away and print in full.
- Immediate jeopardy · J2022-08-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, review of the transportation service report, staff interviews, physician interview, and review of the facility policy regarding change in a resident's condition, the facility failed to timely notify the physician of a significant change of condition for one resident (#55). This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death when Resident #55 experienced abnormally low blood pressures over the course of four hours with no notification to the physician of the abnormal levels until Resident #55 was found unresponsive on [DATE] at 5:45 A.M. and subsequently expiring at the hospital later that evening. This affected one (#55) of four residents reviewed for a change in condition. The facility census was 57 residents. On [DATE] at 1:11 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services #500 were notified that Immediate Jeopardy began on [DATE] at 1:24 A.M. when Licensed Practical…
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 · F2026-02-12 · 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, review of the freezer and refrigerator temperature logs, interview, and policy review, the facility failed to ensure food was stored and prepared under sanitary conditions. This had the potential to affect 56 out of 56 residents who eat food prepared in the kitchen. The facility identified one (Resident #08) who did not eat food by mouth. The facility census was 57.Findings Included:Observation of the dry food storage area on 02/09/26 at 6:33 P.M. revealed a package of opened, undated sandwich buns with mold growing on one of the buns. In addition, there was an opened, undated loaf of white bread. The Dietary Supervisor #132 verified the above items and discarded them.Observation of the walk-in refrigerator in the main kitchen on 02/09/26 at 6:44 P.M. revealed a loosely covered cart of pre-prepared foods with a date of 02/03/26. The cart contained five trays of individual prepared salads, a tray of individual servings of pumpkin pie, two trays of individual servings of coconut cream pie and two trays of individual dishes of pears. Located next to the cart dated…
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 · D2026-02-12 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure discharge summaries were completed. This affected one (#01) of one resident reviewed for discharge. The facility census was 57.Findings include:Review of the closed medical record for Resident #01 revealed an admission date of 11/07/25 and a discharge date of 02/03/26. Diagnoses included Parkinson's disease without dyskinesia with fluctuations, hyperlipidemia, atherosclerotic heart disease of native coronary artery without angina pectoris, major depressive disorder, repeated falls, bipolar disorder, cerebrovascular disease, conversion disorder with seizures or convulsions, encephalopathy, other symbolic dysfunctions, and chronic viral hepatitis B without delta-agent.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was cognitively intact. Resident #01 was assessed to require setup assistance for eating, oral hygiene, and personal hygiene, and partial/moderate assistance for toileting,…
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 · D2026-02-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, and staff interview, the facility failed to ensure care was coordinated with the hospice provider. This affected one (#29) of three residents reviewed for hospice services. The facility census was 57. Findings include:Review of the medical record revealed Resident #29 admitted to the facility on [DATE] with diagnoses including cerebral infarction, cognitive communication deficit, aphasia, hemiplegia (right side), unspecified convulsions, stenosis of right cerebral artery, diabetes, hyperlipidemia, hypertension and history of transient ischemic attacks. Review of the Minimum Data Set (MDS) assessment, dated 11/18/25, revealed Resident #29 was moderately cognitively impaired. Further review of Resident #29's medical record revealed a referral for hospice services on 11/06/25. Review of a progress note, dated 11/12/25 and authored by Social Service Director (SSD) #214, revealed a care conference was held with Resident #29's family and they felt a hospice referral…
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 · D2026-02-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to have physician orders in place for the administration of oxygen. Additionally, the facility failed to ensure appropriate oxygen in use signage was posted. This affected one (#56) of two residents reviewed for oxygen therapy. The facility census was 57.Findings include: Review of the medical record for Resident #56 revealed an admission date of 02/14/2023. Diagnoses included multiple sclerosis, asthma, acute and chronic respiratory failure with hypoxia, morbid obesity, anxiety disorder, and major depressive disorder, recurrent, moderate.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. Review of the physician orders revealed Resident #56 did not have orders for the administration of oxygen.Observations on 02/10/26 at 10:16 A.M. and on 02/11/26 at 10:45 A.M. revealed Resident #56 was receiving oxygen at two liters per minute (lpm)…
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 · D2026-02-12 · 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 review, observations, staff interview, and review of facility policy the facility failed to ensure medications were stored in an appropriate manner. This affected one (#11) of four residents reviewed for medication storage. The facility census was 57.Findings include:Record review for Resident #11 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, chronic venous hypertension, Type II diabetes, and neuropathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had minimally impaired cognition.Review of the physician orders revealed Resident #11 received the following medications: gabapentin oral capsule 300 milligrams (mg), three capsules by mouth twice daily for neuropathy and carvedilol 3.125 mg, one tablet by mouth twice daily for hypertension.Review of the Medication Administration Record (MAR) for 02/10/26 and 02/11/26 revealed Resident #11 was administered gabapentin and carvedilol as ordered.…
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 before2026-02-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure proper enhanced barrier precautions were donned when completing a wound treatment. This affected one (Resident #17) of three residents reviewed for infection control. In addition, the facility failed to develop and implement a water management plan to mitigate the risk of Legionella. This had the potential to affect all residents residing in the facility. The facility census was 57.Findings Include:1. Resident #17 was admitted to facility on 04/28/25. Diagnoses included Alzheimer's Disease, infection of the skin, low back pain, depression, anxiety disorder, diabetes, hypertensive retinopathy, dermatochalasis, chronic kidney disease, diabetic retinopathy, and kidney transplant. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #17 was severely cognitively impaired and suffered with moderate depression. Resident #17 had an infected diabetic foot ulcer; treatments…
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 · D2026-02-12 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure timely provision of a pneumococcal vaccine to a resident once consented. This affected one (Resident #19) of five residents reviewed for pneumococcal vaccine administration. The facility census was 57.Findings Include:Review of the medical record for Resident #19 revealed an admission date of 08/06/2025. Diagnoses included unspecified dementia, chronic kidney disease, type 2 diabetes mellitus without complications, and muscle weakness.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe problems with thinking and memory. The resident was set up assistance for eating, supervision assistance for ambulation, moderate assistance for oral hygiene, upper body dressing, personal hygiene, sit to stand, and transfers, and maximal assistance for toileting, bathing and lower body dressing. Resident #19 was frequently incontinent of bowel and bladder and rejected care and had wandering…
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 · D2026-02-12 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure timely provision of COVID-19 vaccine to a resident once consented. This affected one (Resident #55) of five residents reviewed for COVID-19 vaccine administration. The facility census was 57.Findings Include:Review of the medical record of Resident #55 revealed an admission date of 08/05/25. Diagnoses included nondisplaced lateral mass fracture of first cervical vertebra, subsequent encounter for fracture with delayed healing, muscle weakness, unspecified dementia, and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had moderate problems with thinking and memory. The resident was independent mobilizing in her wheelchair, setup assistance for eating, supervision assistance for sit to stand and transfers, moderate assistance for oral hygiene, toileting, bathing, upper and lower body dressing, and personal hygiene. Resident #55 was always incontinent of bladder and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-12 · 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 observation, resident and staff interviews, medical record review, and review of facility policy, the facility failed to ensure call lights were functional. This affected one (#12) of three residents reviewed for call lights. The facility census was 57. Findings include:Review of Resident #12's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dysphagia, glaucoma, congestive heart failure, atrial fibrillation, heart disease, dementia without behaviors, osteoporosis, benign prostatic hyperplasia, anxiety disorder, edema, gastro-esophageal reflux disease, and hypertension.Review or Resident #12's Minimum Data Set (MDS) assessment, dated 01/05/26, revealed the resident was mildly cognitively impaired. Resident #12 utilized a wheelchair for mobility, required set-up assistance for eating, and moderate assistance with toileting, oral hygiene, dressing, and personal hygiene. Interview with Resident #12 on 02/10/26 at 2:39 P.M. revealed his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-12-29 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the medical record, observations, staff interviews and policy review, the facility failed to ensure Coronavirus-19 (COVID-19) precautions were implemented appropriately for all positive residents. This had the potential to affect all 58 residents residing in the facility. The facility census was 58. Findings include: Review of the medical record for 24 residents (#1, #4, #6, #8, #10, #12, #13, #15, #19, #21, #23, #26, #37, #41, #44, #45, #48, #49, #50, #53, #56, #58, #63, and #64) revealed the residents had tested positive for COVID-19 when the outbreak started in the facility on 12/08/25. Observation on 12/22/25 at 8:06 A.M. revealed Registered Nurse (RN) #30 went into Resident #26's room, who was COVID-19 positive, without wearing a N-95, gown, gloves, or face shield as required, to administer medications wearing a surgical mask only. Interview on 12/22/25 at 8:09 A.M. with RN #30 verified she did not wear the appropriate personal protective equipment (PPE) as required when entering Resident #26's room. RN #30 confirmed Resident #26 was positive for COVID-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.
Show the remaining 8 citations
- Potential for harm · D2025-09-10 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to ensure laboratory (lab) values were completed as ordered by the physician. This affected two (#01 and #44) out of three residents reviewed for labs being completed as ordered by the physician. The facility census was 58. Findings include: 1. Review of Resident #01's chart revealed the resident was admitted to the facility on [DATE] with unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, pressure ulcer to the left buttock unspecified stage, pressure ulcer to the right buttock unspecified stage, traumatic subdural hemorrhage without loss of consciousness, type two diabetes mellitus and cerebral atherosclerosis. Review of Resident #01's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #01 required set up assistance with eating, and oral hygiene. Resident #01 required moderate assistance 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 · D2024-12-11 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to failed to suspend staff pending an abuse investigation. This affected one (Resident #41) of three residents reviewed for abuse. The facility census was 50. Findings include: Record review for Resident #41 revealed she was admitted to the facility on [DATE]. She was under the care of hospice services. Her diagnoses included, heart failure, diabetes mellitus (DM), pruritus, gastro esophageal reflux disease (GERD), dementia, and anxiety disorder. Review of Resident #41's Minimum Data Set (MDS) assessment, dated 09/16/24, revealed she was severely cognitively impaired. Resident #41 was dependent on staff for medication administration. Resident #41 required maximum assistance from staff with eating, oral hygiene, toilet use, bathing, dressing, and personal hygiene. Resident #41 had an indwelling catheter and required hospice services. Review of the Self Reported Incident (SRI) dated 11/11/24 at 12:44 P.M. revealed Resident #41's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility failed to ensure proper infection control measures were maintained during resident care. This affected two (#37 and #41) residents reviewed for incontinence care. The facility census was 50. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 08/01/24. Diagnoses included chronic obstructive pulmonary disease (COPD), type two diabetes mellitus (DM II), and congestive heart failure (CHF). Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require supervision with eating, substantial assistance with toileting, dressing, and transfers, and dependent with bathing. Review of section H for bowel and bladder revealed Resident #37 was always incontinent of bladder and frequently incontinent of bowel. Observation on 12/11/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-08-19 · tag F0727 — failed to provide required RN coverage — widespreadHave 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 observation, interview, and record review, the facility failed to have a registered nurse staffed at least eight hours a day, seven days a week. This had the potential to affect all residents residing at the facility. The facility census was 57. Review of staffing tool on 08/10/22 revealed the absence of a registered nurse scheduled on 08/07/22. During interview on 08/10/22 at 12:43 P.M., the Director of Nursing stated there was not a registered nurse in the building on 08/07/22. She stated there was a call off and the facility had contacted an agency to send a nurse and failed to specify the need for a registered nurse. During interview on 08/11/22 at 10:07 A.M., the Executive Director denied the facility having any waivers.
- Potential for harm · E2022-08-19 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide 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 facility policy, the facility failed to monitor resident weight losses and address changes in nutritional status within a timely manner. This affected four residents (#05, #09, #20, and #52) out of four sampled residents. The facility census was 57. Findings include: 1. Review of the medical record for Resident #05 revealed an admission date of 01/29/22. Diagnoses included Alzheimer's Disease, dementia, psychotic disorder, major depressive disorder, and abnormal weight loss. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #05, dated 05/08/22, revealed the resident had impaired cognition. The assessment noted delusions from the resident, but no rejection of care. The resident required extensive assistance from staff for all activities of daily living (ADLs) except eating (supervision). The assessment indicated the resident had a weight of 86 pounds, had no significant weight loss. Resident #05 was noted to have a therapeutic diet. Review of 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 · Fcited before2019-05-02 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and facility staff interview, the facility failed to maintain separation of clean and soiled linen. This had the potential to affect all 50 residents who reside in the facility. Findings include: Observation of the laundry facility on 04/30/19 with Laundry Worker (LW) #700 at 10:20 A.M. revealed there were 10 bags of hospitality linen (linen for guest who stay at the facility that include sheets, bed spread and towels), seven boxes of various types of round discs that are used on the floor cleaning machine, two plastic containers of drop cloths that are used by maintenance for various projects and two bags of privacy curtains on shelves that were directly across from the washing machines in the washing machine room on the dirty side of the laundry. Interview with LW #700 immediately following the observation confirmed the disc used on the floor cleaning machine that were being stored on the shelves are used throughout the entire building. LW #700 also confirmed the items on the shelves had been stored there for the three years that she had been…
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 · D2019-05-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure fall interventions were in place. This affected on (#18) of four residents reviewed for accidents. The facility census was 50. Findings include: Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnosis including fracture of the humerus, left arm, history of falling, osteoarthritis, generalized muscle weakness, insomnia, and difficulty walking. Review of care plan dated 02/10/19 and revised 02/16/19 revealed Resident #18 was at risk for falls due to status post fall with fracture, unsteady gait, use of psychotropic medications, incontinence, impaired safety awareness as resident attempts to transfer self. Interventions included to provide sensor alarm to bed to alert staff of attempted self transfers. Review of 30 day minimum data set (MDS) assessment dated [DATE] revealed severely impaired cognitive skills for daily decision making, extensive assistance was required with bed mobility,…
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 · D2019-05-02 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 medication administration error rate was five percent (%) or below. 26 medication opportunities were observed with two errors for an error rate of 7.69%. This affected two (#4 and #23) of four residents observed for medication administration. The facility census was 50. Findings include: 1. Observation on 05/01/19 at 8:16 A.M. revealed Licensed Practical Nurse (LPN) #9 administered Calcium 600 milligrams (mg) with Vitamin D 200 international unit (IU) by mouth to Resident #4. Medical record review revealed Resident #4 had a physician order dated 04/11/19 for one tablet of Calcium 600 mg with Vitamin D3 800 IU by mouth daily for osteoporosis. Interview on 05/01/19 at 12:03 P.M., with LPN #9 confirmed Calcium 600 mg with Vitamin D 200 IU was administered to Resident #4 instead of ordered Calcium 600 mg with Vitamin D3 800 IU. 2. Observation on 05/01/19 at 9:39 A.M. revealed LPN #725 administered Fluticasone Propionate nasal spray 50 micrograms (mcg), one spray each nostril, to Resident #23. Medical…
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 LIONSTONE CARE — 24 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 | 2.5 | +0.5 vs chain |
| Health inspection | 2 of 5 | 2.4 | -0.4 vs chain |
| Staffing | 2 of 5 | 1.7 | +0.3 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 23 homes this chain runs (chain average 2.5★, 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 |
|---|---|---|---|---|
| KAZARNOVSKY, SOLOMON | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 50% | since 06/01/2020 |
| STEIN, ABBA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 50% | since 06/01/2020 |
| CUSNER, ADAM | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/27/2025 |
| DEGYANSKY, JEFFREY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2020 |
| GOLDISH, ELIEZER | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/09/2023 |
CMS files one row per role, so the 15 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
This home reported $219K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365652. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, 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.