Covenant Village Care Center
3210 West Fork Road, Cincinnati, OH 45211 · For profit - Corporation · 107 certified beds · (513) 605-3000 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
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for mishandling residents’ money or property (F0565)
- it has 1 actual-harm citation
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 19% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 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 | 3.1% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 7.3% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.3% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 5.2% | 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 | 7.2% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 1.9% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 13.1% | 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 | 3.1% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.1% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.2% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.2% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 91.2% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.9% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.4% | 12.9% | 12.0% | 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.
65.1% 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 175 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 41.9% 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 105 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 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 30% 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 | 65.1%CMS range 58.1–72.6 | 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 | 10.5%CMS range 7.7–13.8 | 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 | 41.9% | 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 | 41.0% | 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 | 41.9% | 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 | 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 | 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 | 100.0% | 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 | 1.5% | 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 | 6.5%CMS range 4.0–10.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 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 107 beds and averages 98.7 residents a day — about 92% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 3.38 hrs/resident/day on weekends vs 3.76 on weekdays — 10% thinner on weekends. RN hours go from 0.52 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · G2024-12-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, staff interviews, interview with Wound Nurse Practitioner (WNP) #175, review of facility policy, and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to adequately assess and monitor residents' skin and failed to timely identify pressure ulcers (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This resulted in Actual Harm when Resident #104 who was admitted without pressure ulcers but was at risk for the development of pressure ulcers, subsequently developed an avoidable facility acquired pressure ulcer which was not identified until it had reached an advanced stage. Resident #104 developed a pressure ulcer which was first identified on 11/05/24 as a stage III (full-thickness skin loss in which adipose [fat] is visible) pressure ulcer on the resident's left gluteus with eschar (dead…
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 before2026-06-11 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review the facility failed to ensure residents were treated with respect and dignity when staff stood over residents as they fed them lunch. This affected two residents (#26 and #48) of twenty four reviewed for dining observation. The facility census was 104.Findings include:1. Medical record review of Resident #26 revealed an admission date of 02/01/25 with diagnoses including; Huntington's disease, ataxia, and dysphagia. Review of the care plan dated 01/30/23 revealed Resident #25 was dependent for eating and required one person assistance with being fed.Review of the minimum data set assessment dated [DATE] revealed Resident #25 was severely cognitively impaired and was dependent upon staff for bringing food and/or drink to mouth.2. Medical record review of Resident #48 revealed an admission date of 08/03/23 with diagnoses including; generalized idiopathic epilepsy and epileptic syndromes, Alzheimer's disease, downs syndrome. Review of the care plan 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 · D2026-04-07 · 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 interview, record review and facility policy review, the facility failed to ensure a safe discharge. This affected one Resident #111 of three residents reviewed for discharge. The facility census was 104.Findings include:Review of the medical record revealed Resident #111 was admitted to the facility on [DATE] and discharged on 01/02/26. Diagnoses included atrial fibrillation, depression, mental disorder, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and essential hypertension.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #111 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) of eight, required set up awsistance for eating, substantial assistance with toileting, substantial assistance with bathing, and set up assistance for personal hygiene.Review of the Letter of Guardianship dated 12/02/25 revealed Resident #111 incompetent for an indefinite time period.Review of the Discharge…
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 · D2026-04-07 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to have a baseline care plan that included pain management and hearing loss. This affected one, (Resident #2) of six residents reviewed for the baseline care plan. The facility census was 104.Findings include:Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included discoid lupus erythematosus, depression, polyarthritis, cardiac arrhythmia, cervical disc disorder, other displaced fracture of upper end of left humerus and rheumatic mitral stenosis.Review of the most recent Minimum Data Set (MDS) 3.0 assessment still in progress dated 02/09/26 revealed Resident #2 was cognitively intact. Review of the baseline care plan dated 03/27/26 revealed Resident #2's pain was not assessed or added to the baseline care plan and hearing loss with a hearing aide was not assessed or added to the baseline care plan.Review of the medical record revealed Resident #2 revealed a hospital discharge…
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 · D2026-04-07 · 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 observation, interviews, policy review and record reviews, the facility failed to ensure residents' activity needs were assessed regularly and addressed in the care plans. This affected two Residents #40 and Resident #54 of three residents reviewed for care plans. The facility census was 104.Findings include:1. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included dizziness, chronic embolism and thrombosis of unspecified vein, dysphagia, alzheimer's disease, and anxiety disorder.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 had severe cognitive impairment, was dependent with eating, dependent with bathing, and dependent with personal hygiene. Review of the Care Area Assessment Summary (CAA) dated 11/11/25, for Resident #40 revealed activities was triggered for a care area and care planning decision. Review of the care plan for Resident #40 revealed no goals or interventions for activities. Review…
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 · D2026-04-07 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management 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 observation, interview, record review, and facility policy review, the facility failed to ensure pain medications were available for a resident. This affected one, (Resident #2) of six residents reviewed for medications. The facility census was 104. Findings include:Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included discoid lupus erythematosus, depression, polyarthritis, cardiac arrhythmia, cervical disc disorder, other displaced fracture of upper end of left humerus and rheumatic mitral stenosis.Review of the most recent Minimum Data Set (MDS) 3.0 assessment still in progress dated 02/09/26 revealed Resident #2 was cognitively intact. Review of the medical record revealed Resident #2's hospital discharge orders dated 03/19/26 revealed Oxycodone (opioid) immediate release five milligrams (mg) every four hours as needed.Review of the medical record revealed Resident #2 had physician orders dated 03/27/26 at 2:45 P.M. revealed Oxycodone oral tablet…
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 · D2026-04-07 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a sanitary environment. This affected one, (Resident #54) of three residents reviewed for a sanitary environment. The facility census was 104.Findings include:Review of the medical record revealed Resident #54 was admitted to the facility on [DATE]. Diagnoses included huntington's disease, essential hypertension, ataxia, corticobasal degeneration, cognitive communication deficit, and dysphagia.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #54 has severe cognitive impairment, required partial assistance with eating, substantial assistance with toileting, substantial assistance with bathing, and partial assistance with personal hygiene.Observation and interview on 04/06/26 at 9:17 A.M. in Resident # 54 room with the Maintenance Director (MD) #82 and the Administrator revealed the floor was covered with small white spots, appearing to be paint chips stuck to floor. Continued observation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-26 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, interview with staff at oral surgeon's office, review of the weather history for Cincinnati, and record review, the facility failed to ensure residents were treated with respect and dignity. This affected one (#12) of two residents reviewed for dignity and respect. The facility census was 102. Findings include:Record review revealed Resident #12 was admitted to facility on 11/09/24. Diagnoses included zygomatic fracture (a break in the cheek bone) and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 required maximum assistance with toileting and dressing and utilized a wheelchair for mobility. Interview with Oral Surgery Office Staff (OSOS) #600 on 09/29/25 at 11:05 A.M. revealed Resident #12 came to the oral surgery clinic at Medical Center (MC) #500 on 01/08/25 for a morning appointment related to her zygomatic fracture. The oral surgery's office (OSO) was called by the MC #500's lobby desk reporting Resident #12 had been dropped off by…
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 · E2024-02-08 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, observations, resident interviews, staff interviews, and policy reviews, the facility failed to ensure resident call lights were in working order on the facility's 200-hall. This affected 12 residents (#12, #14, #19, #23, #32, #42, #54, #57, #59, #74, #91, and #94) of 27 residents reviewed for call lights. The facility census was 95. Findings include: 1. Review of the medical record of Resident #14 revealed an admission date of 07/27/18. Diagnoses included heart failure, weakness, macular degeneration, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had moderately impaired cognition and required extensive assistance from staff with bed mobility and toileting and was dependent on staff for transfers. Multiple observations on 02/05/24 between 9:41 A.M. and 11:00 A.M. revealed Resident #14 had a non-functioning call lights and no other means to call for help. 2. Review of the medical record of Resident #23 revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, review of resident council meeting notes, and record review, the facility failed to address resident concerns timely and ensure staff only attend the meetings if the residents invited them to attend. This affected three (#47, #78, and #88) of four residents who attended the resident council meeting. The facility census was 95. Findings include: Review of the Resident Council meeting notes from September 2023 to January 2024 revealed there was no evidence the facility was following up with the concerns voiced from the residents during resident council meetings. Several staff members attended each resident council meeting. 1. Record review for Resident #47 revealed she was admitted to the facility on [DATE]. Diagnoses included morbid obesity, anxiety disorder, and depression. Review of the Minimum Data Set (MDS) assessment, dated 01/29/24, revealed Resident #47 was cognitively alert. 2. Record review for Resident #78 revealed he was admitted to the facility on [DATE].…
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 · D2024-02-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff interviews, review of the facility's policy, and observations, the facility failed to ensure a resident's safety devices for the prevention of falls were functioning and failed to complete a thorough fall investigation into a resident's fall. This affected two (Residents #27 and #95) of seven residents reviewed for falls. The facility census was 95. Findings include: 1. Record review for Resident #95 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #95 included cerebral infarction and history of fracture of left femur prior to admission. Review of the Minimum Data Set, (MDS) assessment dated [DATE] revealed Resident #95 had severely impaired cognition and required partial assistance with bed mobility. Review of the plan of care, dated 12/21/23, revealed Resident #95 was at risk for falls due to decreased mobility and included an intervention of pressure alarm to the bed, ordered on 01/20/24. Observation on 02/08/24 at 1:56 P.M. with Licensed…
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 17 citations
- Potential for harm · D2024-02-08 · 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 medical record review, observation, staff interview, and policy review, the facility failed to ensure oxygen tubing was changed, labeled, and dated per the physician's order, plan of care, and facility policy and the facility failed to ensure oxygen was administered in a safe manner. This affected one (#49) of one resident reviewed for oxygen use. The facility identified 15 residents who used oxygen. The facility census was 95. Findings include: Review of the medical record for Resident #49 revealed an admission date of 01/06/21. Diagnoses included chronic obstructive pulmonary disease (COPD), and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had severely impaired cognition. The resident utilized a wheelchair for mobility. The resident received oxygen during the assessment period. Review of the care plan dated 01/18/21 revealed Resident #49 had altered respiratory status related to COPD and emphysema. Interventions included to administer oxygen as…
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 · E2020-02-13 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, staff interview, and review of facility policy, the facility failed to appropriately document the number the shift to shift counting of controlled substances in the 100 Hall cart. This had the potential to affect 16 sixteen (#18, #36, #52, #53, #71, #73, #75, #138, #139, #140, #144, #149, #150, #151, #240, #290) residents with controlled substances stored in the 100 hall cart. Facility census was 93. Findings include: Review of the controlled substances shift to shift count sheet for the 100 hall cart revealed the oncoming nurse had not signed the count sheet at the start of the shift on 02/11/20 indicating the count was accurate. Interview on 02/11/20 at 12:46 P.M. with Licensed Practical Nurse (LPN) #720 confirmed she had started work at 9:00 A.M. on 02/11/20 and had counted the controlled substances in the 100 hall cart but had not signed the count sheet indicating the count was accurate. LPN #720 further confirmed the controlled substances count should be done at the change of shift and the sheet should be signed by the off-going nurse 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 · E2020-02-13 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, staff interview, review of facility policy, and review of manufacturer's recommendations the facility failed to discard expired medications and failed to date injectable medication upon opening to ensure it was discarded in a timely manner in accordance with manufacturer's recommendations. This had the potential to affect the six (#24, #71, #142, #288, #289, #290) residents. The census was 93. Findings include: 1. Review of record for Resident #24 revealed an admission date of 02/01/19 with a diagnosis of diabetes. Review of February 2020 physician orders for Resident #24 revealed an order for Levemir insulin. Observation on 02/11/20 at 12:30 P.M. of the 200 Hall medication storage room with Registered Nurse (RN) # 90 revealed an open and undated vial of Levemir insulin was in storage for Resident #24. Interview on 02/11/20 at 12:30 P.M. with RN #90 confirmed the vial of Levemir insulin for Resident #24 was open and undated and she could not determine when it was expired. 2. Observation on 02/11/20 at 12:35 P.M. of the 200 Hall medication…
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 · E2020-02-13 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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, resident and staff interview and policy review, the facility failed to ensure meals were served in a safe and appetizing temperature. This had the potential to affect 33 residents residing on the 100 halls, except Resident #20 who does not receive dietary services. Facility census was 93. Findings include: Interview on 02/10/20 at 11:11 A.M., Resident #79 reported she feels nothing is cooked properly, the vegetables are hard and cold. Resident #79 reported she eats a lot of carry out foods that her daughter brings her. Interview on 02/10/20 at 1:19 P.M., revealed Resident #72 reported the meatloaf was inedible and the eggs are not warm in the mornings. Interview on 02/11/20 at 2:29 P.M., revealed residents at the resident council meetings complaining about breakfast being cold sometimes. Observation on 02/13/20 at 7:30 A.M., revealed dietary staff in kitchen preparing meals for the 100 halls. Staff were plating scrambled eggs, oatmeal, French toast and turkey sausage. Observation on 02/13/20 at 7:45 A.M. revealed dietary staff delivering the first 100 hall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2020-02-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and policy review the facility failed to store food properly and maintain a clean and sanitary kitchen to prepare food. This had the potential to affect 92 out of 93 residents residing in the facility, except one (#20) resident who did not receive food from the kitchen. Facility census was 93. Findings include: An initial tour of the kitchen was completed on 02/10/20 at 8:42 A.M. through 9:05 A.M. with Dietary Manager (DM) #580 revealed there were three shelves on the top shelf was a box of eggs, on the second shelf below the eggs was a bag of bagels, and on the bottom shelf was a container of shredded cheese with very loose fitting saran wrap. Upon further observation of the three compartment sink there were cookie sheet pans in the washing compartment, when the sanitizing compartment was checked with the facility's approved sanitation test strips and revealed no level of sanitizer was in the sink. Observation during tour of the sanitizing bucket used to clean surfaces, where food was prepared, and using facility approved sanitation test…
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 · D2020-02-13 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation and resident and staff interview, the facility failed to accommodate a residents need by providing a resident with an alternate mobility device while her motorized wheelchair was being repaired. This affected one (#40) of 19 residents sampled during the survey. The census was 93. Findings include: Review of the medical record for Resident #40 revealed an admission date of 02/22/17 with diagnoses which included diabetes, end stage renal disease, morbid obesity, and hemiplegia. Review of Minimum Data Set (MDS) for Resident #40 dated 01/03/20 revealed resident was cognitively intact required extensive assistance of two staff with activities of daily living, was non-ambulatory, used a wheelchair for mobility, and considered it very important to be able to do her favorite activities. Review of care plan for Resident #40 dated 11/15/19 revealed resident had a self-care performance deficit related to left hemiplegia/hemiparesis and morbid obesity and was unable to transfer without use of Hoyer lift and non-ambulatory status. Interventions included 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 · D2020-02-13 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident representative and staff interview and policy review, the facility failed to ensure a resident was afforded with the choice of food preferences with each meal. This affected one (#11) of one reviewed for choices. The facility census was 93. Findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnosis including but not limited to corticobasal degeneration, cognitive communication, mild cognitive impairment, dementia and transient ischemic attack. Resident #11 has a representative to make decisions on her behalf. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #11 has severe impairment, ability to understand others, impaired vision, with adequate hearing and requires total dependence for transfers, toileting, personal hygiene, eating and bed mobility with two-person assist. Review plan of care dated 09/18/19 stated State Tested Nursing Assistant (STNA) check meal trays closely to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-02-13 · 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 facility policy, the facility failed to ensure resident code status was communicated consistently and accurately to the staff. This affected two (#24 and #18) of two residents reviewed for advanced directives. The census was 93. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 02/01/19 with a diagnosis of diabetes. Review of the Minimum Data Set (MDS) for Resident #24 dated 01/01/20 revealed resident was cognitively intact and required extensive assistance of two staff with activities of daily living (ADLs). Review of February 2020 physician orders for Resident #24 revealed residents code status was do not resuscitate comfort care (DNRCC)-Arrest. Review of the code status form for Resident #24 dated 02/04/19 located under the advanced directive section of the medical record revealed the resident and the resident's revealed resident's code status was DNRCC, not DNRCC Arrest. Review of the online medical record dashboard for Resident #24 revealed resident was to be a DNRCC…
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 · D2020-02-13 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to ensure resident Minimum Data Set (MDS) assessments accurately reflected resident psychiatric diagnoses. This affected one (#18) of six residents reviewed for unnecessary medications. The census was 93. Findings include: Review of the medical record for Resident #18 revealed an admission date of 12/23/19 with a diagnosis of chronic kidney disease. Review of the Minimum Data Set (MDS) for Resident #18 dated 12/30/19 revealed resident was cognitively impaired, was coded as negative for the presence of behavioral symptoms and required extensive assistance of two staff with activities of daily living (ADLs). Further review of the MDS revealed resident was not coded in Section I for psychiatric/mood disorder diagnoses including anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, or post-traumatic stress disorder (PTSD). Review of admitting medical history and physical for Resident #18 dated 12/26/19 revealed resident was admitted with a diagnosis of anxiety. Review of clarification…
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 · D2020-02-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident, resident representative and staff interview and policy review, the facility failed to provide dental care for dependent residents. This affected one (#11) of one resident reviewed for activities of daily living. The facility census was 93. Findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnosis including but not limited to corticobasal degeneration, cognitive communication, mild cognitive impairment, dementia and transient ischemic attack. Resident #11 has never refused care and has a representative. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #11 has severe impairment, adequate hearing, impaired vision and require total dependence for personal hygiene including combing hair and brushing teeth. Resident is incontinent of bowel and bladder. Resident is also total dependent for eating and toileting. Resident can understand others and is understood by others. Review plan…
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 · D2020-02-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure as needed anti-anxiety medication had a stop date and failed to thoroughly document target behaviors and non-pharmacological interventions offered prior to administration of an as needed anti-anxiety medication. This affected one (#18) of six residents reviewed for unnecessary medications. The census was 93. Findings include: Review of the medical record for Resident #18 revealed an admission date of 12/23/19 with a diagnosis of chronic kidney disease. Review of the Minimum Data Set (MDS) for Resident #18 dated 12/30/19 revealed resident was cognitively impaired, was coded as negative for the presence of behavioral symptoms and required extensive assistance of two staff with activities of daily living (ADLs). Review of history and physical for Resident #18 dated 12/26/19 revealed resident was admitted with a diagnosis of anxiety. Review of care plan for Resident #18 dated 12/23/19 revealed resident received psychotropic medication. Interventions included the following:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-01-04 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, 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 residents residing in the facility except for one resident (#3) identified by the facility as receiving nothing by mouth (NPO). The facility census was 79. Findings include: On 01/02/19 from 8:15 A.M. to 8:35 A.M., an initial tour of the kitchen was conducted with Dietary Director (DD) #120. During the observation the following concerns were observed, and all the concerns were verified by DD #120. a) In the refrigerator there was a half of gallon of milk with a use by date of 12/30/18. b) In the refrigerator there was a gallon of milk with a use by date of 01/01/18. c) In the refrigerator there was a plastic container of mushrooms with a date of 11/01/18. d) In the refrigerator there was a cheese ball with an expiration date of 12/31/18. e) In the refrigerator there was a plastic container of chocolate pudding with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-01-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the Ohio Administrative Code (OAC) and policy review, the facility failed to appropriately document resident's advanced directives for code status on a valid form signed by a physician. This affected one (#246) out of 25 residents reviewed for advanced directives during the survey. Facility census was 79. Findings include: Resident #246 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, acute cystitis, heart failure, and history of transient ischemic attack and cerebral infraction. A comprehensive Minimum Data Set (MDS) assessment was not completed or required yet due to the resident's recent admission. Review of Resident #246's electronic medical record revealed the current physician's orders contained an order for Do Not Resuscitate Comfort Care (DNRCC). A review of the resident's paper chart revealed an Ohio DNR Identification Form that contained no physician or physician designee signatures.…
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 · D2019-01-04 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to provide a resident with the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), giving the resident the right to a demand bill, when the resident was discharged from Medicare Part A skilled services. This affected one (#50) out of three residents reviewed for beneficiary notices. The facility census was 79. Findings include: Record review revealed Resident #50 was admitted to the facility on [DATE] with the following diagnoses; type 2 diabetes mellitus, hyperlipidemia, unspecified dementia without behavioral disturbance, benign prostatic hyperplasia with lower urinary tract symptoms, cognitive communication deficit, dysphagia, unsteadiness on feet and end stage renal disease. Review of Resident #50's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to have severe cognitively impairment and require extensive assistance with bed mobility, transfers, dressing, toileting and personal…
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 · D2019-01-04 · 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 medical record review, staff interview and policy review, the facility failed to provide a resident or their representatives with written bed hold notices during absences from the facility. This affected one (#88) out of three residents reviewed for hospitalizations. The facility census was 79. Findings include: Record review revealed Resident #88 was admitted to the facility on [DATE] with the following diagnoses; age related osteoporosis with current pathological fracture, unspecified mood disorder, panic disorder, constipation, pain, abnormal involuntary movements, cognitive communication deficit, other symbolic dysfunctions, hypothyroidism, unspecified dementia without behavioral disturbance, Alzheimer's disease, Parkinson's disease, unsteadiness on feet, muscle weakness, major depressive disorder, psychotic disorder with hallucinations due to known physiological condition, heart failure, anxiety disorder, bipolar disorder, personal history of urinary tract infections and sepsis. Review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-02-08 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, the facility failed to post daily staffing data at the beginning of each shift. This had the potential to affect all 95 residents who resided in the facility. Findings include, Observation and interview on 02/06/24 at 3:52 P.M. revealed the facility did not have Benefits Improvement and Protection Act (BIPA) information posted including the current census and list of licensed and unlicensed nursing staff directly responsible for the resident care at the beginning of a shift. Human Resource Director (HRD) #337 walked to a table located next to the receptionist area and held up a picture frame with a flyer posted inside. HRD #337 stated the BIPA should be posted in the picture frame. HRD #337 confirmed she attempted to post the BIPA in the picture frame, however, someone continued to move it. Observation on 02/08/24 at 7:52 A.M. revealed no BIPA was posted on the table located near the receptionist desk. Observation and interview on 02/08/24 at 8:00 A.M. revealed HRD #337 walked toward the receptionist desk with a paper in hand. HRD #337…
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 · C2020-02-13 · tag F0680 — widespreadEnsure the activities program is directed by a qualified professional.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on personnel file review, staff interview and review of a job description, the facility failed to ensure a qualified Activity Director was on staff to oversee the facility's overall activity services. This had the potential to affect every resident residing in the facility. The census was 93. Findings include: Review of personnel file for Activity Director (AD) #5 revealed employee was hired on 09/24/14 as a State Tested Nursing Assistant (STNA). Further review of personnel file revealed AD #5 became a Co-Activity Director on 05/13/19 but was not a qualified activity professional and had not completed a training course in activities approved by the state. Review of personnel file for AD #725 revealed former employee was a qualified activity professional and her last day worked was 11/25/19. Interview on 02/11/20 at 3:30 P.M. with AD #5 confirmed she had served as Activity Director for the facility since 05/13/19 but was not a qualified activity professional and had not completed a state approved activity training course. Interview on 02/12/20 at 1:35 P.M. with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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 | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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 $2.5M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366399. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-02-08, 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.