Courtyard At Seasons
7100 Dearwester Drive, Cincinnati, OH 45236 · For profit - Limited Liability company · 45 certified beds · (513) 984-7274 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- 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
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 6.7% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 6.7% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.2% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.2% | 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 | 3.4% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 19.2% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 15.6% | 25.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.8% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 10.3% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 8.8% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 98.0% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.2% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.2% | 12.9% | 12.0% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
61.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 207 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 9.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 111 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.50 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% 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 | 61.9%CMS range 55.2–67.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 8.0–14.1 | 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 | 9.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 32.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 9.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.3% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 2.0% | 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 | 5.9%CMS range 3.7–10.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 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 45 beds and averages 39.7 residents a day — about 88% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.19 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.00 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 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 3.86 hrs/resident/day on weekends vs 4.32 on weekdays — 10% thinner on weekends. RN hours go from 1.12 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Fcited before2025-09-04 · 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 safely serve food in a manner to avoid possible contamination and food borne illnesses. This had the potential to affect all of the residents residing in the facility who received food from the facility kitchen. The facility identified one (Resident #36) who received no nutrition by mouth. The facility census was 42 residents.Findings include:Observation on 09/03/25 at 12:05 P.M of trays being assembled revealed Dietary Aide (DA) #10 donned gloves, grabbed a tray off the cart, reviewed the tray ticket, and picked up a sandwich off the steam table. DA #10 placed food on the plate using serving utensils and removed and replaced the lid to the heated serving compartment with gloved hands. DA #10 then picked up the next tray, reviewed the ticket, picked up a chicken breast with gloved hands and placed it on a plate. Interview on 09/03/25 at 12:10 P.M. with DA #10 at 12:10 P.M. confirmed he had donned gloves and residents' food (sandwich and chicken breast) directly with his gloved hands after…
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 before2025-09-04 · 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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) during direct care for residents with orders for enhanced barrier precautions (EBP). This affected one (Resident #50) of three residents reviewed for EBP. The facility also failed to take preventative measures to minimize the risk of legionella per the facility's water management plan. This had the potential to affect all of the residents residing in the facility. The facility census was 42 residents.Findings include: 1.Review of the medical record for Resident #50 revealed an admission date of 08/26/25 with diagnoses including but perforation of intestine, colostomy status, and hypertension.Review of the physician's orders for Resident #50 revealed an order dated 08/26/25 for the resident to be on enhanced barrier precautions related to presence of an ostomy. Observation on 09/03/25 at 8:21 A.M. of colostomy care for Resident #50 per Licensed Practical Nurse (LPN) #30 and Certified Nursing…
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 · E2025-09-04 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and review of the facility policy, the facility failed to provide a comfortable homelike atmosphere for residents dining in the skilled nursing dining room. This affected six (Residents #3, #12, #15, #21, #27, #38) and had the potential to affect all of the residents residing in the facility with the exception of one facility-identified resident (#36) who did not receive nutrition by mouth. The facility census was 42 residents. Findings include:Observation on 09/02/25 at 4:53 P.M. of dinner in the skilled nursing dining room revealed staff served residents on trays directly from the serving cart. The staff did not remove the plates from the meal trays. Interview on 09/02/25 at 4:55 P.M. with Certified Nursing Assistant (CNA) #104 confirmed resident meals were served on trays and staff did not remove the plates of food, utensils, and beverages from the tray. Observation on 09/03/25 at 12:34 P.M. of lunch in the skilled dining room revealed staff served residents on trays directly from the serving cart. The staff did not remove the plates from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-04 · 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
Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident code status was correctly noted in the medical record This affected three (Residents #9, #28, and #31) of 16 residents reviewed for advance directives. The facility census was 42 residents. Findings include: 1.Review of the medical record for Resident #28 revealed an admission date of 12/08/24 with diagnoses including atherosclerotic heart disease, hypertension, major depressive disorder, anxiety disorder, and cardiomyopathy. Review of the paper chart for Resident #28 revealed a signed Do Not Resuscitate (DNR) form dated 12/18/24 indicating the resident's code status was DNR Comfort Care. Review of the Minimum Data Set (MDS) assessment for Resident #28 dated 06/17/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the active physician orders for Resident #28 in the electronic health record revealed an order dated 08/18/25 for the resident to be a full code status. Interview on 09/03/25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-04 · 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
Based on medical record review, observation and staff interview, facility failed to ensure staff provided the appropriate level of supervision during mealtime. This affected one (Resident #38) of six facility-identified residents who required supervision with meals. The facility census was 45. Findings include: Review of the medical record for Resident #38 revealed an admission date of 08/28/24 with diagnoses including cerebral atherosclerosis, dysphagia, and depression. Review of the physician's orders for Resident #38 revealed an order dated 11/01/24 for a regular diet, pureed texture and nectar fluids consistency.Review of the Minimum Data Set (MDS) assessment for Resident #38 dated 06/05/25 revealed the resident had severe cognitive impairment and required supervision from staff with eating.Review of care plan for Resident #38 dated 06/09/25 revealed the resident was at severe nutritional and hydration risk. The goal of the care plan was for resident to be able to safely and effectively chew and swallow a pureed diet with nectar thick liquidsReview of the physician's orders for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-04 · 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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure insulin was dated upon opening. This affected one (Resident #31) of six residents who had orders for insulin. The facility failed to ensure expired medications were discarded. This affected one (Resident #54) of 42 residents reviewed for medication storage. The facility census was 42 residents.Findings include:1. Review of the medical record for Resident #31 revealed an admission date of 11/11/24 with diagnoses including dementia, type two diabetes, and hyperlipidemia. Observation on 09/03/25 at 3:54 P.M of medication storage with Registered Nurse (RN) #76 revealed the Lantus insulin pen for Resident #31 had not been dated upon opening. Interview on 09/03/25 at 3:55 P.M. with RN #76 confirmed Resident #31's Lantus insulin pen had not been dated upon opening. 2. Review of the medical record for Resident #54, revealed an admission date of 08/26/25 with diagnoses including myoneural disorder, rhabdomyolysis, and type two diabetes.Review of the active…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-04 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents received dental services. This affected one (Resident #43) of three residents reviewed for dental services. The facility census was 42 residents. Findings include: Review of the medical record for Resident #43 revealed an admission date of 09/15/23 with diagnoses which included hereditary idiopathic neuropathy, peripheral venous insufficiency, arthritis, and depressionReview of the admission packet for Resident #43 dated 07/19/23 revealed the resident signed the admission packet which noted the facility would arrange for physician visits as authorized under the agreement for ancillary services prescribed by a physician. Review of the physician's orders for Resident #43 revealed an order dated 08/22/23 for resident to receive ancillary services as needed including dental services.Review of the Minimum Data Set (MDS) for Resident #43 dated 05/20/25 revealed the resident was cognitively intact and required staff assistance with activities 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 · D2025-09-04 · 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
Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered appropriate pneumococcal immunizations. This affected one (Resident #42) of eight residents reviewed for immunizations. The facility census was 42 residents.Findings include: Review of the medical record for Resident #42 revealed an admission date of 11/09/22 with diagnoses including chronic atrial fibrillation, gastrointestinal hemorrhage, and hyperlipidemia.Review of the immunization record for Resident #42 revealed the resident received Pneumovax 23 (PPSV23) on 11/10/22.Review of the Minimum Data Set (MDS) assessment for Resident #42 dated 08/15/25 revealed the resident was cognitively intact and the resident's pneumococcal immunizations were completed.Interview on 09/04/25 at 12:20 P.M with the Director of Nursing (DON) confirmed the facility did not offer Pneumococcal Conjugate Vaccine (PCV)15, PCV20, or PCV21 vaccines to Resident #42 due to accidentally marking his pneumococcal immunizations as complete.Review of the facility policy titled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-07-12 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure 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 observation of tray line and a test tray, resident, family, and staff interview, review of the resident council meeting minutes, review of the facility's policy, and record review, the facility failed to ensure food was served at an appetizing temperature and acceptable palatability. This had the potential to affect 40 residents who received food from the kitchen. The facility identified one resident (#37) who did not receive food from the kitchen. The facility census was 41. Findings include; Interview on 07/05/22 at 10:28 A.M. with Resident #141 stated the facility's food was often served cold and this issue was ongoing. Interview on 07/05/22 at 11:15 A.M. with Resident #142 stated the food was served cold. Resident #142 stated this was really the only concern or complaint regarding the facility's food. Interview with Resident #4's spouse on 07/05/22 at 12:29 P.M. stated there were times the hot food was served cold. Observation on 07/06/22 at 11:34 A.M. revealed Dietary [NAME] (DC) #500 placed a food thermometer in a pan of mixed vegetables without sanitizing 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 before2022-07-12 · 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, record review, review of the facility's policy, and staff interview, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 40 residents who received food from the kitchen. The facility identified one resident (#37) who did not receive food from the kitchen. The facility census was 41. Findings include: Observation and interview during the initial tour of the facility's kitchen on 07/05/22 at 8:12 A.M. revealed Dietary Manager (DM) #362 was standing in the kitchen area without a hair net covering her hair. The dining room manger (DRM) #322 was standing at the counter with no hair net covering her hair. DM #362 confirmed the findings. DM #362 provided a tour of the kitchen and confirmed an employee lunch was located inside the facility's refrigerator. A pound cake was observed on a shelf in the refrigerator with no label or date. DM #362 confirmed a large bag of open frozen cookies with no label or date. DM #362 opened the free standing ice cream cooler and revealed four three gallon tubs of ice cream with no lids. DM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2022-07-12 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of Resident Council meeting minutes, review of the facility's policy, and resident and staff interviews, the facility failed to respond to grievances identified at the Resident Council meetings. This affected two (Residents #8 and #12) of three residents interviewed regarding Resident Council meetings. The facility census was 41. Findings include: Record review for Resident #8 revealed an admission date of 10/14/21. Diagnoses included chronic kidney disease stage three, anxiety disorder, and polyarthritis. Review of the Minimum Data Set (MDS) assessment, dated 04/22/22, revealed Resident #8 had mild cognitive impairment. Record review for Resident #12 revealed an admission date of 01/24/21. Diagnoses included Parkinson's disease, bipolar disorder, and adult failure to thrive. Review of the quarterly MDS assessment, dated 05/01/22 revealed Resident #12 was cognitively intact. Interviews during Resident Council meeting on 07/07/22 at 10:40 A.M. revealed Resident #8 stated the facility staff does not follow up on concerns brought to the attention 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 · D2022-07-12 · 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 staff interview, medical record review, review of the facility's Self-Reported Incidents and investigations, and policy review, the facility failed to complete thorough investigations of allegations of resident abuse. This affected two (Resident #16 and #97) of three residents reviewed for abuse. The facility census was 41. Findings include: 1. Review of the medical record for Resident #97 revealed an admission date of 02/21/22 with a discharge date of 03/23/22. Diagnoses included multiple fractures of pelvis and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 had intact cognition. Resident #97 required one-person extensive assistance with transfers, dressing, toileting, and bathing. Review of Resident #97's medical record revealed no documentation of an incident occurring on 02/25/22. Review of the self-reported incident (SRI) control number 218359 revealed Resident #97 reported an allegation of neglect on 02/25/22.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-12 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, review of the facility's policy, and record review, the facility failed to provide written notification of the resident's transfer to the hospital to the residents and/or their representatives. This affected two (Residents #27 and #32) of four residents reviewed for transfers. The facility census was 41. Findings include: 1. Review of the medical record for Resident #32 revealed an admission date of 06/01/22 with surgical aftercare following surgery, pain in right hip and pain in right leg. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact. Review of the physician's order dated 05/25/22 revealed Resident #32 was to go to the hospital. Review of the progress note dated 05/25/22 at 7:26 P.M. revealed Resident #32 had uncontrollable pain in her right hip and right leg. Pharmacological and non-pharmacological interventions were attempted without relief. The physician ordered Resident #32 be sent to the emergency room for further…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-12 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 staff interview, review of facility's policy, and record review, the facility failed to provide bed hold notices to the residents and their representatives when the residents transferred to the hospital. This affected two (Residents #27 and #32) of four residents reviewed for bed hold notices. The facility census was 41. Findings included: 1. Review of the medical record for Resident #32 revealed an admission date of 06/01/22 with surgical aftercare following surgery, pain in right hip and pain in right leg. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact. Review of the physician's order dated 05/25/22 revealed Resident #32 was to go to the hospital. Review of the progress note dated 05/25/22 at 7:26 P.M. revealed Resident #32 had uncontrollable pain in her right hip and right leg. Pharmacological and non-pharmacological interventions were attempted without relief. The physician ordered Resident #32 be sent to the emergency room for further…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-12 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the facility's policy, and staff interviews, the facility failed to hold quarterly care conferences with residents. This affected one (Residents #10) of 16 residents reviewed for care conferences. The facility census was 41. Findings include: Review of the medical record for Resident #10 revealed an admission date of 09/08/21. Diagnoses included congestive heart failure (CHF), Parkinson's disease, type two diabetes mellitus, atrial fibrillation, liver disease, and chronic kidney disease, stage III. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Review of the care conferences from 06/21/21 to 07/07/22 revealed Resident #10 had care conferences on 06/21/21, 09/20/21, and 12/08/21. There was no additional care conference documentation available after 12/08/21. Interview on 07/07/22 at 9:41 A.M. with Social Services Director (SSD) #300 verified all care conference documentation was in the electronic medical records.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, review of the facility's policy, and record review, the facility failed to ensure residents were weighed as ordered, residents were re-weighed as needed and timely documentation of addressing the resident's weight changes. This affected one (Resident #10) of five residents reviewed for nutrition. The facility identified four residents with unplanned significant weight gain or loss. The facility census was 41. Findings include: Review of the medical records for Resident #10 revealed an admission date of 09/08/21. Diagnoses included congestive heart failure, Parkinson's disease, type two diabetes mellitus type two, atrial fibrillation, liver disease, and chronic kidney disease, stage III. Review of the Minimum Data Set (MDS) assessment, dated 04/22/22, revealed Resident #10 was cognitively intact and required supervision and setup help only for eating. Review of the physician's orders dated 10/29/21 revealed Resident #10 had an order on for monthly weights. Review of Resident #10's weights revealed the following weights: 166.6 pounds (lbs.) on 01/07/22; 174.0…
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 before2019-05-09 · 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 facility policy review, the facility failed to label, date, and discard expired food items from the walk-in refrigerator and freezer. The facility also failed to serve food in a sanitary environment. This had the potential to affect all 38 residents who receive food from the kitchen. Findings include: 1. On 05/06/19 from 6:15 P.M. to 6:35 P.M., an initial tour of the kitchen was conducted with Kitchen Manager (KM) #66. During the observation, the following concerns were observed, and all the concerns were verified by KM #66. a. In the refrigerator, there was a container of cut up cucumbers, a container of chopped boiled eggs, a container of cherry tomatoes and a container of shredded cheese sealed with no dates or used by dates. b. In the freezer, there were a plastic bag of mozzarella sticks, two plastic bags of french fries that were rewrapped, a bag of hash browns rewrapped in a clear plastic bag, two five-pounds of lamb rewrapped sealed in plastic covering and one five-pound turkey breast wrapped in aluminum foil with no dates or used…
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 before2019-05-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, policy review, and review of the Center for Disease Control guidelines, the facility failed to implement appropriate infection control precautions. This affected one (#91) of four residents observed for medication administration, and two residents (#37 and #38) reviewed on the facility's infection control logs. The facility identified one resident who was on intravenous medication. This had the potential to affect all 38 residents residing in the facility. Findings include: 1. Record review for Resident #91 revealed the resident was admitted to the facility on [DATE] with diagnoses including Methicillin resistant staphylococcus aureus (MRSA), bacteremia and clostridium difficile. Observation of medication administration on 05/08/19 at 9:00 A.M. with Registered Nurse (RN) #18 revealed that RN #18 flushed Residents #91's central line with heparin and did not clean the needless access tip with alcohol prior to administration. Interview on 05/08/19 at 9:02 A.M.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-09 · 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 information on the Minimum Data Set (MDS) assessments. This affected two (#2 and #36) of 18 residents reviewed for accuracy. The facility census was 38. Findings include: 1. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease and anxiety. Review of physicians orders, dated 04/23/18, revealed Resident #2 was taking risperidone (an antipsychotic) 0.25 milligrams (mg.) twice daily. Review of the annual MDS assessment, dated 05/01/19, revealed Resident #2 took an antipsychotic seven days out of seven days for the look-back period. However, the next section in the MDS stated the resident did not receive an antipsychotic since the last MDS assessment (which was a quarterly MDS assessment dated [DATE]). Interview on 05/09/19 at approximately 3:15 P.M. with the Administrator and Registered Nurse (RN) #49 verified that the MDS dated [DATE] was coded wrong in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-09 · 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, facility policy review, observations and resident, family and staff interviews, the facility failed to implement the resident's comprehensive care plans. This affected three (#12, #21, and #88) of 19 residents reviewed for care plans. The facility census was 38. Findings include: 1. Review of medical record for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses included end stage renal disease with dependence on renal dialysis. Review of the Minimum Data Set (MDS) assessment, dated 04/09/19, revealed Resident #12 was cognitively intact. Review of the care plan, dated 05/03/19, revealed to check the shunt site (implanted tube to which an artery and vein in your arm is attached and provides larger than normal volume of blood flow for effective hemodialysis) every shift and to notify the physician of absence of thrill or bruit. Review of the Treatment Administration Record (TAR) for 05/2019 revealed no documentation that the shunt site was checked every…
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 · D2019-05-09 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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, family interview, staff interview, observation, and review of facility policy, the facility failed to ensure a resident who required assistance from staff received personal hygiene routinely. This affected one of one residents reviewed for dental hygiene. The facility identified all 39 residents required assistance with activities of daily living. Findings include: Review of medical record for Resident #21 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dysphagia, pneumonitis due to inhalation of food and vomit, cognitive communication deficit and dementia. Review of the quarterly MDS assessment, dated 02/16/19, revealed Resident #21 was moderately impaired cognitive status and was totally dependent on staff for personal care. Review of the care plan, dated 07/24/18, revealed Resident #21 has oral/dental health problems and provide mouth care as per Activity of Daily Living (ADL) personal hygiene. Review of Resident #21's ADL oral care sheet revealed it…
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 · D2019-05-09 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, the facility failed to ensure a shunt site was checked every shift and the weights were obtained per physician orders for a resident receiving dialysis services. This affected one (#12) of one resident reviewed for dialysis. The facility identified one resident was receiving dialysis at the time of the survey. The facility census was 38. Findings include: Review of medical record for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses included end stage renal disease with dependence on renal dialysis. Review of the Minimum Data Set (MDS) assessment, dated 04/09/19, revealed Resident #12 was cognitively intact. Review of the care plan, dated 05/03/19, revealed to check shunt site (implanted tube to which an artery and vein in your arm is attached and provides larger than normal volume of blood flow for effective hemodialysis) every shift and to notify the physician of absence of thrill or bruit. Review of the Treatment…
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.
- No harm found · Ccited before2022-07-12 · 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 staff interview, review of the facility's policy and risk assessment, and review of the employee files, the facility failed to ensure the facility newly hired staff received the second step of the tuberculin skin test (TST). This had the potential to affect all 41 residents residing in the facility. The facility census was 41. Findings include: Review of the employee file for State Tested Nursing Assistant (STNA) #326, revealed a hire date of 06/07/22. Further review of the employee file revealed a form titled Initial TB testing for Residents and Health Care Workers, dated 01/28/21, revealed the first TB step was completed on 05/27/22 and results were read on 05/30/22. However, the second step was blank and not completed. Review of the employee file for STNA #316 revealed a hire date of 05/12/22. Review of the form titled Initial TB testing for Residents and Health Care Workers, dated 01/28/22, revealed the first TB step testing was completed on 04/27/22 and results read on 04/29/22. However, the second step was blank and not completed. Review of the employee file for STNA…
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CCRC OPS MB1-T LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/03/2014 |
| GA HC REIT II TRS MIDWEST CCRC HOLDINGS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/03/2014 |
| HCI CWP CAPITAL LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2022 |
| HCI CWP INVESTOR LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2022 |
| HCI CWP LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2022 |
| HCI CWP PARENT LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2022 |
| HEALTHCARE GA HOLDINGS GENERAL PARTNERSHIP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/03/2014 |
| HEALTHCARE GA HOLDINGS NT-HCI, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/03/2014 |
| HEALTHCARE GA HOLDINGS-T LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/03/2014 |
| HEALTHCARE GA OPERATING PARTNERSHIP T LP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/03/2014 |
| HG VORA OPPORTUNISTIC CAPITAL FUND (CAYMAN) II LP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2022 |
| HG VORA OPPORTUNISTIC CAPITAL FUND II LP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2022 |
| HG VORA OPPORTUNISTIC CAPITAL MASTER FUND II LP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2022 |
| J.P. MORGAN INVESTMENT MANAGEMENT, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/01/2023 |
| KGT INVESTMENTS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2022 |
| NORTHSTAR HEALTHCARE INCOME INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/03/2014 |
| NORTHSTAR HEALTHCARE INCOME OPERATING PARTNERSHIP LP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/03/2014 |
| NORTHSTAR HEALTHCARE JV HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/19/2017 |
| NORTHSTAR HEALTHCARE JV LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/19/2017 |
| NORTHSTAR TK HEALTHCARE OPERATING COMPANY LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/19/2017 |
| NORTHSTAR TK HEALTHCARE REIT LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/19/2017 |
| NRF HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/10/2017 |
| NRFC HEALTHCARE HOLDING COMPANY LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/31/2015 |
| PINTA VITALITY LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2022 |
| SGT INVESTMENTS LP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2022 |
| VENTAS MS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/01/2023 |
| VENTAS SSL, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/01/2023 |
| VENTAS, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/01/2023 |
| VTR SHI VENTURE, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/01/2023 |
| WCR (US) SPV, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2022 |
| WCR SPV, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2022 |
| CHEESEMAN, HEATHER | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 06/13/2022 |
| BAKER, DANA | Individual | CORPORATE OFFICER | — | since 05/01/2023 |
| CUMMINGS, CHRISTIAN | Individual | CORPORATE OFFICER | — | since 05/01/2023 |
| FRY, BRIAN | Individual | CORPORATE OFFICER | — | since 05/01/2023 |
| SMITH, MICHAEL | Individual | CORPORATE OFFICER | — | since 05/01/2023 |
| WOOD, BRIAN | Individual | CORPORATE OFFICER | — | since 05/01/2023 |
| SL SEASONS, L.L.C. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2014 |
32 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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 365798. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-04, 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 →
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