Hillebrand Nursing And Rehabilitation Center
4320 Bridgetown Road, Cincinnati, OH 45211 · For profit - Individual · 108 certified beds · (513) 574-4550 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $16,801 in federal fines (most recent 2024-06-28)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 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 fell from 3 to 2 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 | 7.5% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 8.4% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.3% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 31.1% | 30.1% | 6.5% | typical for the 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 | 3.9% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 21.8% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.9% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.1% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.5% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.9% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 93.8% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.2% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.0% | 12.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.44 | 1.73 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.20 | 1.80 | 1.80 | better |
‡ 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.
48.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 213 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 44.4% 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 90 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 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 48.6%CMS range 42.6–54.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.3%CMS range 6.9–12.4 | 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 | 44.4% | 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 | 36.7% | 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 | 31.1% | 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 | 96.1% | 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 | 1.6% | 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 | 6.4%CMS range 3.9–9.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 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 108 beds and averages 99.9 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 3.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 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 3.29 hrs/resident/day on weekends vs 3.57 on weekdays — 8% thinner on weekends. RN hours go from 0.58 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% 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.
32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-06-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, review of facility in-service records, review of a personnel file, review of the safety inspection bus checklist, review of the facility's Self-Reported Incidents (SRIs), review of facility policies, review of the emergency medical services (EMS) run report, review of hospital documentation, resident interview, and staff interview, the facility failed to ensure a resident was safely secured in the wheelchair with an appropriate seat belt during transportation in a facility bus from an activity department outing. This resulted in Immediate Jeopardy when one resident (#05) was placed at potential risk for serious life-threating harm and/or injuries when on 05/28/24, Activity Director (AD) #300 abruptly stopped the facility bus, causing Resident #05 to fall forward out of his wheelchair, hitting another resident, and then landing on the floor. During the fall, Resident #05 sustained a degloving/laceration (a traumatic injury that results in the top layers of skin 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 · F2026-03-26 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview, the facility failed to ensure a Registered Nurse (RN) was working in the facility for at least eight consecutive hours a day seven days a week. This had the potential to affect all of the residents residing in the facility. The facility census was 98 residents.Findings include: Review of the facility staffing schedules revealed on 03/22/26 the census was 96 residents and there was no RN on the schedule for this date. Interview on 03/26/26 at 1:04 P.M. with the Director of Nursing (DON) verified there was no RN working during the 24 hours on the date of 03/22/26. The DON verified there needed to be an RN working eight hours of each day. Interview on 03/26/26 at 1:30 P.M. with the Administrator verified there was no RN working on 03/22/26 and an RN was required to work eight hours of each day.
- Potential for harm · D2026-03-26 · 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
Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure residents experienced a dignified dining experience. This affected one (Resident #104) of three residents reviewed for dignity. The facility census was 98 residents. Findings include:Review of the medical record for Resident #104 revealed an admission date of 07/21/23 with diagnoses including essential tremors, epilepsy, Alzheimer's disease, anxiety disorder and dysphagia. Review of the Minimum Data Set (MDS) assessment for Resident #104 dated 01/02/26 revealed the resident had severe cognitive impairment and required assistance with meals. Observations of the afternoon meal in the dining room on 03/23/26 at 12:00 P.M. revealed Resident #104 was seated at a table with other residents. Certified Nursing Assistant (CNA) #329 brought Resident #104's tray to the table and stood over the resident and began feeding the resident large bites. Resident #104 pushed CNA #329's hand away. CNA #329 did not provide the resident with the opportunity to feed herself, 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 · Dcited before2026-03-26 · 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 medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure resident call lights were accessible to the resident. This affected one (Resident #86) of three residents reviewed for accidents and hazards. The facility census was 98 residents. Findings include: Review of the medical record for Resident #86 revealed an admission date of 07/22/23 with diagnoses including vascular dementia, respiratory failure, and dysphagia. Review of the care plan for Resident #86 dated 12/10/25 revealed the resident was at risk for falls related to deconditioning, and gait and balance problems. Interventions including the following: provide a safe environment, ensure the call light was working, ensure the call light was within reach. Review of the Minimum Data Set (MDS) for Resident #86 dated 03/04/26 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Observation on 03/23/26 at 12:21 P.M. of Resident #86 revealed the resident was sitting up in 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 · D2026-03-26 · 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 advance directives were accurate. This affected two (Residents #1 and #11) of three residents reviewed for advance directives. The facility census was 98 residents. Findings include: 1.Review of the medical record for Resident #1 revealed an admission date of 10/11/24 with diagnoses including unspecified bacterial pneumonia, acute pulmonary edema, and Parkinsonism unspecified.Review of the physician's orders for Resident #1 revealed an order dated 12/11/25 for the resident to be a full code. Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 12/16/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of a paper form in Resident #1's chart undated revealed the resident's code status was do not resuscitate comfort care-arrest (DNRCC-A). Interview on 03/24/26 at 2:29 P.M. with Licensed Practical Nurse (LPN) #114 verified the physician's order in the electronic health record was 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 · D2026-03-26 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, review of facility Self-Reported Incidents (SRIs), review of staff witness statements, observation, staff interview, and review of the facility policy, the facility failed to ensure residents were free from verbal/emotional abuse. This affected one (Resident #104) of three residents reviewed for abuse. The facility census was 98 residents.Findings include:Review of the medical record for Resident #104 revealed an admission date of 07/21/23 with diagnoses including essential tremors, epilepsy, Alzheimer's disease, anxiety disorder and dysphagia. Review of the Minimum Data Set (MDS) assessment for Resident #104 dated 01/02/26 revealed the resident had severe cognitive impairment and required assistance with meals. Review of the facility SRI initiated 03/23/26 and completed 03/27/26 revealed the facility's investigation determined Certified Nursing Assistant (CNA) #329 had verbally/emotionally abused Resident #104. CNA #329 was terminated from employment as a result of the abuse. Review of the SRI included review of a signed witness statement per CNA…
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 · D2026-03-26 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to ensure allegations of abuse were reported to the state agency in a timely manner. This affected one (Resident #21) of three residents reviewed for abuse. The facility also failed to report allegations of abuse to the state agency. This affected one (Resident #10) of three residents reviewed for abuse. The facility census was 98 residents.Findings include: 1.Review of the medical record for Resident #21 revealed an admission date of 02/10/25 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and paroxysmal atrial fibrillation. Review of the Minimum Data Set (MDS) assessment for Resident #21 revealed the resident was cognitively intact. Record review of the facility SRI initiated 03/16/26 revealed an allegation of physical abuse in which Resident #21 reported on 03/13/26 that Registered Nurse (RN) #204 allegedly struck her ear with a towel. Interview on 03/25/26 at 4:41 PM with RN # 204…
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 · D2026-03-26 · 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
Based on medical record review, review of facility Self-Reported Incidents (SRIs), review of staff witness statements, observation, staff interviews, and review of the facility policy, the facility failed to prevent possible further abuse by not removing staff from the facility during the investigation. This affected three (Residents #104, #21, and #10) of three residents reviewed for abuse. The facility census was 98 residents.Findings include: 1.Review of the medical record for Resident #104 revealed an admission date of 07/21/23 with diagnoses including essential tremors, epilepsy, Alzheimer's disease, anxiety disorder and dysphagia. Review of the Minimum Data Set (MDS) assessment for Resident #104 dated 01/02/26 revealed the resident had severe cognitive impairment and required assistance with meals. Review of the facility SRI initiated 03/23/26 and completed 03/27/26 revealed the facility's investigation determined Certified Nursing Assistant (CNA) #329 had verbally/emotionally abused Resident #104. CNA #329 was terminated from employment as a result of the abuse. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-26 · 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, review of facility fall investigations, resident interview, and staff interview the facility failed to ensure safe resident transfers to prevent falls. This affected one (Resident #4) of three residents reviewed for accidents and hazards. Based on medical record review, observation, and staff interview, the facility failed to follow safe swallowing recommendations during mealtime. This affected one (Resident #104) of three residents reviewed for accident hazards. The facility census was 98 residents.Findings include: 1.Review of the medical record for Resident #4 revealed an admission date of 06/09/23 with diagnoses including vascular dementia, major depression, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #4 revealed the resident was cognitively intact and required the assistance of one staff with transfers. Review of the nurse progress note for Resident #4 dated 03/23/26 at 7:23 A.M. revealed the nurse was called to the resident room because the resident had fallen in the bathroom while a staff person was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-26 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, and staff interview, the facility failed to ensure residents had adaptive utensils at meals as ordered by the physician. This affected one (Resident #104) of 24 residents sampled. The facility census was 98 residents. Findings include: . Review of the medical record for Resident #104 revealed an admission date of 07/21/23 with diagnoses including essential tremors, epilepsy, Alzheimer's disease, anxiety disorder, and dysphagia. Review of the Minimum Data Set (MDS) assessment for Resident #104 dated 01/02/26 revealed the resident had severe cognitive impairment and required assistance with meals. Review of the physician's orders for Resident #104 dated March 2026 revealed the resident received a mechanical soft diet. The orders specified the resident needed partial feeding assistance such as set up, cueing, sips of fluids between one to two bites, divided plate and built-up utensils and no straws. Review of the dietary ticket for Resident #104 dated 03/23/26 for lunch revealed the resident was to receive built-up utensils at meals.…
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 before2026-03-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff donned proper personal protective equipment (PPE) when providing gastrostomy tube (g-tube) care to residents with physician's orders for enhanced barrier precautions (EBP.) The affected one (Resident #23) of two facility-identified residents with orders for EBP. The facility census was 98 residents. Findings include: Review of the medical record for Resident #23 revealed an admission date of 08/18/25 with diagnoses including congestive heart failure, atrial fibrillation, and gastrostomy status (g-tube) status. Review of the physician's orders for Resident #23 revealed an order dated 9/17/25 for EBP due to presence of a g-tube. Observation of g-tube feeding for Resident #23 on 03/25/26 at 10:23 A.M. per Licensed Practical Nurse (LPN) #114 revealed the nurse did not don a gown prior to administration. There was a sign outside Resident #23's door indicating gloves and gowns should be worn while providing care. Interview on 03/25/26 at 10:29 A.M. with LPN…
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 21 citations
- Potential for harm · D2026-03-26 · 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 and staff interview, the facility failed to ensure residents were offered pneumococcal vaccines and failed to ensure resident medical records included documentation of receipt or refusal of the vaccine. This affected two (Residents #4 and #8) of five residents reviewed for infection control. The facility census was 98 residents. Findings include: 1.Review of the medical record for Resident #4 revealed an admission date of 08/24/23 with diagnoses including vascular dementia, malignant neoplasm of bladder, and atrial fibrillation. Review of the immunization record for Resident #4 revealed it did not include documentation of administration of the pneumococcal vaccine, did not include documentation of the resident receiving the vaccine prior to admission to the facility, nor did the record include documentation of resident refusal of the vaccine. 2.Review of the medical record for Resident #8 revealed an admission date of 11/06/22 with diagnoses including end stage renal disease, nonrheumatic aortic stenosis, and diabetes mellitus type two. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-04 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, the facility failed to ensure resident's medical record contained documentation for completed care and services provided by staff. This affected one (#216) out of three residents reviewed for quality of care. The facility census was 103. Findings included Review of the medical record for Resident #216 revealed an admission date of 02/20/25 and a discharge home on [DATE] with private care givers and hospice. Resident #216 expired in the home on [DATE]. Diagnoses included Alzheimer's disease with late onset, dementia with agitation and anxiety. Review of the discharge Minimum Data Set (MDS) assessment for Resident #216 dated 02/25/25 was not completed at the time of the survey. Review of the baseline plan of care for Resident #216 dated 02/20/25 revealed the resident was admitted to nursing facility for a respite due to Alzheimer's disease. Interventions include use of my personal preferences to help develop plans of care and daily routine, manage all activities…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and policy review, the facility failed to obtain additional instructions/orders from the physician when a vacuum-assisted closure (wound vac) was not available and/or not applied as ordered. Additionally, the facility failed to obtain instructions/orders to provide care for a residents peripherally inserted central catheter (PICC) line. This affected one (#130) of three reviewed for quality of care. The facility census was 103. Findings include 1. Review of the medical record for Resident #130 revealed an admission date of 10/09/23 and a transfer to the hospital on [DATE]. Diagnoses include surgical aftercare following surgery on the digestive system, ulcerative colitis with complications, rectal abscess, ileostomy, moderate protein calorie malnutrition, depression, hypokalemia, ileus, and hypothyroidism. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #130 revealed the resident had an intact cognition. Resident #130 was coded…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-02-22 · 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 — the official record, unedited, may be distressing
Based on observation, staff interview and policy review, the facility failed to ensure food items were properly sealed and dated and that the ice machine was clean. This had the potential to affect all 97 residents residing in the facility. All 97 residents were served food from the kitchen. The facility census was 97. Findings include: Observation on 02/13/23 at 6:45 P.M. of the walk-in refrigerator revealed two bags of undated shredded cheese, an open and undated box of assorted pastries, an undated bag of carrots, and an undated bag of hard-boiled eggs, which were all confirmed by Dietary Staff #405 at the time of the observation. Observation on 02/13/23 at 6:53 P.M. of the ice machine in the kitchen revealed a black discoloration on the inside of the lid and the side of the ice machine, which was confirmed by Dietary Manager #690 at the time of the observation. Review of the undated facility policy titled DATE MARKING revealed any ready-to-eat, potentially hazardous food prepared and held in refrigeration should be marked utilizing an established procedure to ensure food safety.
- Potential for harm · E2023-02-22 · 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 observations, family and staff interviews, the facility failed to provide a clean and homelike environment. This affected five (#30, #82, # 347, #349, and #350) of five residents reviewed for environment. The facility census was 97. Findings include: Interview on 02/14/23 at 2:32 P.M., with Resident #30's daughter, during a family interview, revealed she was concerned with the dust and debris hanging from Resident #30's bathroom vent in the ceiling. Resident #30's daughter stated she has brought this to the attention of management in the past and it has not been resolved. Resident #30's daughter stated she is concerned that her mother is breathing the dust and debris in each time she uses the restroom. Observation on 02/14/32 at 2:35 P.M., revealed Resident #30's bathroom ceiling vent had visible debris and powdered like substance that appeared to be dust hanging from he ceiling vent. Interview on 02/15/23 at 2:14 P.M., with the Housekeeper (HK) #1000 revealed the housekeeping staff will clean the resident rooms and bathrooms daily. HK #1000 could not confirm how often he…
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 · E2023-02-22 · 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 observations and staff interview the facility failed to ensure proper storage of medications including ensuring that expired medications were not being used. This affected one of the three medication carts reviewed and one out of two medication storage rooms in the facility. This had the potential to affect 18 residents (#1, #8, #12, #19, #27, #33, #42, #55, #57, #61, #73, #78, #86, #155, #245, #247, #346, #347) due to expired medications. The facility census was 97. Findings include: Observations on 02/14/23 at 8:24 A.M. of the 3rd floor medication room revealed outdated medications. The outdated medications found were Certavite Senior multivitamins dated 08/2021, Iron 325mg dated 12/2022, Calcium 600mg dated 05/2022, Vitamin D 400 iu dated 11/2019, Zinc 50mg dated 11/2022, Calcium Citrate plus Vitamin D dated 07/2017, Fish Oil 1200mg dated 11/2021, Vitamin B6 dated 03/2021. Interview on 02/14/23 at 8:27 A.M. with Licensed Practical Nurse (LPN) #505 confirmed the above outdated medications. Observations on 02/14/23 at 9:00 A.M. of the 3rd floor, Team 2 medication cart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-22 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and record review, the facility failed to provide a resident with dignity and respect regarding his personal possessions. This affected two (#21 and #27) of three residents reviewed for dignity and respect of personal possessions. The facility census was 97. Findings include. 1. Record review for Resident #21 revealed and admission date of 01/19/18. Resident #21's diagnoses included: essential primary hypertension, gastro- esophageal reflux disease, heart disease, respiratory failure, hyperlipidemia, anxiety disorder, insomnia, edema, major depressive disorder, tachycardia, dysarthria following cerebral infarction, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/08/22, revealed Resident #21 he was mildly cognitively impaired. Further review of the MDS assessment revealed Resident # 21 required extensive assistance from staff with bed mobility, dressing, toilet use, and personal hygiene. He was totally dependent on staff 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 · Dcited before2023-02-22 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed ensure residents were provided form of communication, to communicate the needs of the resident and have their personal needs met. This affected two resident (#87 and #60) of two residents reviewed for communication. The facility census was 97. Findings include: Review of the medical record for Resident #87 revealed she was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, type two diabetes mellitus with diabetic chronic kidney disease, end stage renal disease, Parkinson's disease, bipolar disorder, mixed hyperlipidemia, thrombocytopenia, major depressive disorder, vitamin d deficiency, and unspecified psychosis not due to a substance or known physiological condition. Review of the admission Minimum Data Set (MDS) assessment, dated 01/17/23, revealed this resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 02. This resident was assessed to require…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-22 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and review of the facility policy, the facility failed to ensure the resident's attending physician was notified of significant weight loss. This affected one (#22) of eight residents reviewed for nutrition. The facility census was 97. Findings include: Review of the medical record for Resident #22 revealed an admission date of 01/12/23, with diagnoses including fracture to the right tibia and right fibula, Alzheimer's disease, chronic kidney disease, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 01/18/23, revealed resident was cognitively impaired and required supervision and one-person physical assistance with activities of daily living (ADLs). Resident's height was 67 inches and weight was 161 pounds. Review of the admission physician orders for Resident #22 dated 01/12/23 revealed orders for a regular diet with thin liquids and Boost nutritional supplement 120 milliliters (ml) twice daily. Review of the nutrition and hydration care plan for Resident #22 dated 01/13/23 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 · D2023-02-22 · 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
Based on record review, staff interview, and review of policies, the facility failed to develop care plans for residents receiving dialysis services. This affected one (#38) of four residents reviewed for dialysis. The facility identified six residents receiving hemodialysis services. The facility census was 97. Findings include: Review of the medical record for Resident #38 revealed an admission date of 01/15/23 with diagnoses including metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), pleural effusion, diabetes mellitus (DM), cirrhosis of the liver, end stage renal disease (ESRD), atherosclerotic heart disease. Review of the comprehensive admission Minimum Data Set (MDS) for Resident #38 dated 01/21/23 revealed resident was cognitively intact, required extensive assistance with activities of daily living (ADLs.) Review of the admission physician orders for Resident #38, dated 01/15/23, revealed an order for the resident to receive hemodialysis at the facility's dialysis clinic on Monday, Wednesday, and Friday; and an order to observe dialysis shunt to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-22 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to revise care plans as needed. This affected two (#15 and #23) of eight residents reviewed for pressure ulcers and unnecessary medications. The facility census was 97. Findings include: 1. Review of the medical record for Resident #23 revealed she was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dysphagia following unspecified cerebrovascular disease, unspecified nondisplaced fracture of second cervical vertebra, subsequent encounter for fracture with routine healing, anxiety disorder, chronic kidney disease, hyperparathyroidism, epilepsy, unspecified not intractable, without status epilepticus, and moderate protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/31/22, revealed this resident had moderately impaired cognition evidenced by a Brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-22 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing 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 and staff interviews, the facility failed to arrange for a resident to receive services to address hearing difficulties. This affected one (#52) of two residents reviewed for communication. The facility census was 97. Findings include: Review of the medical record for Resident #52 revealed she was admitted to the facility on [DATE]. Diagnoses included atrial fibrillation, acute kidney failure, hypothyroidism, and other specified disorders of the peritoneum. Review of the annual Minimum Data Set (MDS) assessment, dated 12/02/22, revealed this resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 05. This resident was assessed to require extensive assistance for bed mobility, dressing, toileting, and personal hygiene as well as supervision for eating. Resident #52 was identified on the assessment as having moderate hearing difficulty with no hearing aid or other hearing appliance used. Review of the plan of care for hearing initiated on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-22 · 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 medical record review, staff interviews, observations, review of policies, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess resident's skin, failed to notify the physician when areas developed and change soiled gloves during a dressing change. This affected three (#15, #23, and #155) of four residents reviewed for pressure ulcers. The facility census was 97. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 01/13/21. Diagnoses for Resident #15 includes: chronic obstructive pulmonary disease (COPD), acute respiratory failure, cellulitis of the left lower limb, urinary tract infection, atrial fibrillation, benign prostatic hypertrophy, hypertension, hyperlipidemia, major depressive disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessments for Resident #15 dated 11/18/22 and 12/06/22 revealed resident was cognitively impaired. No hallucinations,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-02-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, record review, and policy review, the facility failed to ensure a resident who smokes was following the facility policy on securing smoking materials. This affected one (#349) of two residents identified as smokers. The facility census was 97. Findings include: Record review for Resident #349 revealed he was admitted to the facility on [DATE]. His diagnoses included malignant neoplasm of extrahepatic bile, chronic obstructive pulmonary disease, Parkinson's Disease, major depressive disorder, hypothyroidism, and overactive bladder. Review of New admission Minimum Data Set (MDS) assessment dated , 01/26/23, revealed Resident # 349 was cognitively intact. Further review of the MDS assessment Resident #349 required limited assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident # 349 required supervision from staff with walking and eating. Review of Resident #349's care plans revealed a Tobacco Use 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 · D2023-02-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to implement interventions for a resident with significant weight loss and failed to monitor weights per policy. This affected three (#22, #23, and #87) of eight residents reviewed for nutrition. The facility census was 97. Findings include: 1. Review of the medical record for Resident #23 revealed she was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dysphagia following unspecified cerebrovascular disease, unspecified nondisplaced fracture of second cervical vertebra, subsequent encounter for fracture with routine healing, anxiety disorder, chronic kidney disease, hyperparathyroidism, epilepsy, unspecified not intractable, without status epilepticus, and moderate protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/31/22, revealed this resident had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-22 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview and policy review, the facility failed to ensure a peripherally inserted central catheter (PICC) was maintained. This affected one (Resident #151) of three residents reviewed for IV therapy services. The facility census was 97. Findings include: Review of the medical record for Resident #151 revealed an admission date of 12/29/22 with diagnoses including fracture right humerus, acute osteomyelitis, diabetes mellitus (DM), and end stage renal disease (ESRD). Resident #151 was discharged on 02/03/23. Review of admission physician orders for Resident #151 dated 12/29/22 revealed an order for Vancomycin per IV three times weekly on Monday, Wednesday, and Friday. Review of the orders revealed they did not include orders regarding a dressing or flush to the PICC. Review of the December 2022 and January 2023 Treatment Administration Record (TAR) for Resident #151 revealed no documentation a dressing change or flush was ever performed to the PICC line during Resident #151's stay. During interview on 02/16/23 at 12:08 P.M., Licensed Practical Nurse (LPN)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-22 · 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 record review and interview, the facility failed to ensure residents had an appropriate diagnosis for the use of anti-psychotic medications. This affected two (Residents #23 and #51) of five residents reviewed for unnecessary medications. The facility census was 97. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 01/04/21 with a diagnosis of dementia, COVID-19, dysphagia, anxiety disorder, major depressive disorder, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #51, dated 01/31/23, revealed the resident was cognitively impaired. The assessment revealed no hallucinations, delusions, or rejection of care noted. Review of the physician orders for Resident #51 in February 2022 revealed orders for Seroquel (anti-psychotic) 25 milligrams (mg) in the morning for anxiety and Seroquel 25 mg at bedtime for agitation. During interview on 02/16/23 at 1:39 P.M., the Director of Nursing (DON) confirmed that anxiety and agitation are not correct approved indications for the usage of Seroquel. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-02-22 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, policy review and manufacturer's instructions, the facility failed to properly clean and sanitize the glucometer before and after use. This affected one (#68) of one resident observed for glucometer check. The census was 97. Findings include: During observation on 02/14/23 at 8:06 A.M., Resident #68 was sitting in his wheelchair in the common area with four other residents in the area. Licensed Practical Nurse (LPN) #700 gathered all her supplies at the medication cart. She cleansed the glucometer with an alcohol wipe and did not let it dry. The nurse did have gloves on prior to completing the blood glucose. After obtaining Resident #68's glucose reading, she returned the glucometer to the medication cart without cleaning it. Interview on 02/14/23 at 8:10 A.M. with LPN #700 confirmed that she used an alcohol wipe to cleanse the glucometer before using it to obtain the blood sugar of Resident #68. Review of the facility policy titled Glucometer Testing Policy and Procedure, undated, revealed Each resident that has finger sticks ordered will have…
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 before2020-02-06 · 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 facility policy and review of the facility maintenance binder the facility failed to perform monitoring per their policy. This had the potential to affect all residents of the facility. The census was 95. Findings include: Review of facility undated policy entitled Water Management Program - Legionella, revealed a preventative maintenance program that included weekly water flushes of seldom used drains, quarterly flush of hot water storage tanks, annual visual inspection of water tank, and monthly inspect and disinfection of ice machines. An attached sheet had handwritten information dated 01/20/20 indicated quarterly visual inspections would be done March, June, September, and December each year; temperatures would be checked weekly on Fridays and disinfect would be checked monthly on a Monday. Review of the facility maintenance binder revealed an untitled form with room numbers. Across the top of the form was written 4/19, 2019, shower heads. The binder also included weekly water temperature check logs for resident rooms. Interview on 02/05/20…
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 · D2020-02-06 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, interviews and review of Medscape the facility failed to ensure the medication error rate was less than five percent when extended release (ER) and delayed release (DR) medications were crushed. There were 27 opportunities with three medication errors for a medication error rate of 11.11 percent. This affected one (Resident #89) of four residents observed. The facility identified 18 residents (#16, #24, #25, #34, #36, #37, #38, #39, #42, #45, #48, #54, #62, #66, #67, #70, #74, and #89) on Registered Nurse (RN) #51's assignment. The census was 95. Findings include: Review of the medical record for Resident #89 revealed an admit date of 02/20/19 with diagnoses including Alzheimer's, hypertension, irritable bowel syndrome, degenerative disc disease, osteoarthritis, and epilepsy. Review of an annual Minimum Data Set assessment dated [DATE] indicated severe cognitive deficits, no behaviors or rejections of care, and a need for extensive assist of one for 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.
- No harm found · C2020-02-06 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facilities surveys, observation and interview, the facility failed to ensure survey results including complaint surveys for the preceding three years were available for review. This had potential to affect all residents in the facility. The census was 95. Findings include: A resident council meeting was held on 02/06/20 at 11:32 A.M At the time of the meeting 10 Residents (#21, #27, #34, #40, #52, #57, #67, #86, #89, and #196) were interviewed and all 10 residents reported they were unaware of any posting in regard to the Ohio Department of Health survey results. Review of the facilities surveys for the last three years revealed multiple complaints were conducted including the dates of 03/05/19 and 10/12/19. Observation on 02/06/20 at 1:00 P.M. revealed the second and third floors bulletin board had a notice indicating a survey result book was in the library. The survey book did not include the three preceding years of surveys including complaint investigations. The survey results for 03/05/19 and 10/12/19 were not in the survey book. Interview on 02/06/20 at 1:40…
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
$16,801 in federal fines across 1 penalty.
- $16,801 — penalty dated 2024-06-28
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| JMG FAMILY LLP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 49% | since 06/25/2009 |
| GLASS, JAMES | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER | 24% | since 01/01/2014 |
| RIDGELY, DEBORAH | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 24% | since 01/01/2014 |
| SUER, DANIEL | Individual | W-2 MANAGING EMPLOYEE | — | since 08/07/2006 |
| SCHNEIDER, MICHELLE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 01/01/2014 |
CMS files one row per role, so the 10 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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.
This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365045. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, 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.