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Indianspring Of Oakley

4900 Babson Place, Cincinnati, OH 45227 · For profit - Limited Liability company · 144 certified beds · (513) 561-2600 Medicare & Medicaid certified

Call the home — (513) 561-2600 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Aug 2019Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations$17,345 in federal fines1 Medicare payment denial
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • 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
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $17,345 in federal fines (most recent 2025-07-01)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (63%) runs well above the national median (45%)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Urgent care / clinic
3914 Miami Rd · (866) 676-3348 · Call to confirm hours
Pharmacy
7398 Wooster Pike · (513) 271-3131 · Call to confirm hours
Grocery
6216 Madison Rd · (513) 785-0000 · Call to confirm hours
Park
4600 Muchmore Rd · (513) 561-5151 · Typically dawn to dusk
Place of worship
4448 Berwick Ave · (513) 271-5490

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 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.0%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight9.6%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.2%0.9%typical for the state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms12.1%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.8%3.2%3.3%worse
Long-stay residents whose ability to walk worsened3.6%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication12.9%25.5%18.9%better
Long-stay residents given the seasonal flu vaccine94.9%94.5%95.3%typical
Long-stay residents with pressure ulcers5.1%3.4%4.7%typical
Long-stay residents with worsening bladder/bowel control34.6%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.8%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine91.7%75.6%79.4%better
Short-stay residents rehospitalized after admission21.1%24.9%22.6%typical
Short-stay residents with an outpatient ER visit8.2%12.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.621.731.67typical
Long-stay outpatient ER visits per 1,000 resident days1.381.801.80better

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.

49.1% 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 93 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.1%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
71.9%U.S. median 56.6%
Met the expected recovery
0.35U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 71.9% 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 64 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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.1%CMS range 40.8–58.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.3–14.310.7%Oct 2022–Sep 2024no 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 discharge71.9%56.6%Oct 2024–Sep 2025CMS 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 discharge64.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge68.8%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened9.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.3%CMS range 3.5–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.091.02Oct 2022–Sep 2024CMS 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

0.97
RN hours/ resident / day
0.60
LPN hours/ resident / day
2.13
Aide hours/ resident / day
3.70
Total nurse hours/ resident / day
0.69
RN hoursweekends
63.0%
Total nursing turnover
54.5%
RN turnover

How full it usually is: this home is certified for 144 beds and averages 134.2 residents a day — about 93% occupied, or roughly 10 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 3.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.97 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 3.40 hrs/resident/day on weekends vs 3.83 on weekdays — 11% thinner on weekends. RN hours go from 1.09 to 0.69 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

3
deficiencies at the latest standard inspection (2025-07-01)
5
at the previous standard inspection (2023-07-13)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2025-07-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 staff witness statements, review of hospital records, review of facility Interdisciplinary Team (IDT) fall follow-up notes, staff interview, review of online clinical resources per Medline Plus Medical Encyclopedia, and review of the facility policy, the facility staff failed to safely and properly position a resident in bed during incontinence care. Actual Harm occurred on 05/30/25 when Certified Nursing Assistant (CNA) #521 rolled Resident #108 who was in a raised bed away from the aide and onto the floor, resulting in a right nondisplaced intertrochanteric hip fracture which required a hospital admission and subsequent surgical repair of the right hip fracture on 06/02/25. This affected one (Resident #108) of three residents reviewed for falls. The facility census was 123 residents. Findings include: Review of the medical record for Resident #108 revealed an admission date of 01/09/25 with diagnoses including end stage renal disease, left below the knee amputation (BKA), diabetes mellitus, and intellectual disabilities. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-04-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to adequately assess and monitor a resident's skin which resulted in Actual Harm for Resident #20 who was admitted to the facility without pressure ulcers and developed a stage three pressure ulcer (a full thickness skin break into the subcutaneous tissue which did not go into muscle or bone) to the right ischium which was not identified until it had reached an advanced stage. This affected one (Resident #20) of three residents reviewed for pressure ulcers. The facility census was 113. Findings include: Review of the medical record for Resident #20 revealed an admission date of 02/29/20 with diagnoses including Alzheimer's disease, anemia, atherosclerotic heart disease of coronary artery, and hypertension. Review of the care plan for Resident #20 dated 02/12/24 revealed the resident had potential for skin impairment related to impaired mobility, fragile skin, and incontinence. Interventions…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-07-01 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview and review of facility policy, the facility failed to ensure refrigerated food was maintained at or below 41 degrees Fahrenheit (F). This had the potential to affect 121 of 123 residents of the facility, excluding two facility-identified residents who received no food by mouth (NPO). The facility census was 123 residents. Findings include: Observation of the facility kitchen on 06/23/2025 at 9:28 A.M. revealed the inside of the walk-in refrigerator was warm. The thermometer on the outside of the door read 60 degrees F. There was no thermometer was located inside the refrigerator. Interview on 06/23/25 at 9:28 A.M. with Executive Chef (EC) #601 confirmed that the temperature of the walk-in refrigerator located was 60 degrees F, and all refrigerated foods should be maintained at or below 41 degrees F. Observation on 06/25/2025 at 11:59 A.M. of the refrigerator in the first-floor dining room kitchenette revealed the digital thermostat on the unit was 65 degrees F. The temperature fluctuated during the lunch meal from 57 degrees F to 67 degrees F.…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-07-01 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview, the facility failed to ensure garbage cans in the main kitchen were covered with lids. This had the potential to affect 121 of 123 residents of the facility, excluding two facility-identified residents who received no food by mouth (NPO). The facility census was 123 residents. Findings include: Observation on 06/23/25 at 9:28 A.M. revealed there were three garbage cans in use in the main kitchen which did not have lids. Interview on 06/23/25 at 9:29 A.M. Executive Chef (EC) #601 confirmed the three garbage cans in use in the main kitchen did not have lids and the lids would need to be ordered. Observation on 06/25/25 at 9:48 A.M. revealed the three garbage cans in use in the main kitchen did not have lids. Interview on 06/25/25 at 9:49 A.M. with EC #601 confirmed the three garbage cans in use in the main kitchen still did not have lids, but they were being procured. Interview on 06/26/25 at 1:00 P.M. with the Administrator on 06/26/2026 confirmed the facility did not have a policy regarding garbage can covers for the kitchen.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-01 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    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, interview with home health staff, and review of the facility policy, the facility failed to ensure appropriate information was communicated to resident family and home health provider upon discharge. This affected one (Resident #271) of three residents reviewed for discharge rights. The facility census was 123 residents. Findings include: Review of the medical record for Resident #271 revealed an admission date of 01/28/25 with diagnoses including protein-calorie malnutrition, malignant neoplasm of breast, acute kidney injury, dehydration, adult failure to thrive, iron deficiency anemia and intellectual disabilities. Resident #271 discharged from the facility back to her group home on [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #271 dated 01/31/25 revealed the resident had severe cognitive impairment, was frequently incontinent of bowel and occasionally incontinent of bladder, was dependent on staff assistance with activities of daily…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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, interview with staff and emergency services provider (EMT), review of resident medical records, hospital records, emergency services (EMS) reports, and manufacturer guidelines, the facility failed to ensure Resident #109 was safely assisted with personal care to prevent a fall with injury and failed to thoroughly investigate the fall. This affected one (Resident #109) of five residents reviewed for accidents. Findings include: Resident #109 was admitted on [DATE] with a readmission date of 12/29/24 for diagnoses including acute and chronic respiratory failure with hypoxia, diabetes mellitus type 2 (DM2), cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, peripheral vascular disease, and seizures. Review of Resident #109's care plan initiated 03/17/24 for an activities of daily living (ADL) self-care deficit due to impaired mobility and balance revealed the resident required extensive assistance of two staff for bed mobility, toileting, and transfers. Review of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-15 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews, and review of manufacturer's instructions, the facility failed to ensure staff prime an insulin pen prior to administration. This affected one (#11) out of three reviewed for medication administration. The facility census was 110. Findings include: Review of the medical record for Resident #11 revealed an admission date of 08/31/24. Diagnoses included type two diabetes mellitus (DM II), chronic pulmonary edema, and congestive heart failure (CHF). Review of the care plan dated 08/31/24 revealed Resident #11 had diabetes mellitus. Interventions included administering diabetes medication as ordered. Review of the physician order dated 08/31/24, revealed Resident #11 was ordered Humalog (quick acting insulin) Kwik Pen 100 unit per milliliter (ml) solution pen-injector, inject subcutaneously with meals for DM II per a sliding scale. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had intact cognition 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-04 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure medications were stored in a safe and secure manner. This affected one (#4) of four residents observed for medications. The facility census was 98. Findings include: Record review for Resident #4 revealed an admission date of 04/03/24 with diagnoses including atrial fibrillation, history of transient ischemic attack, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact. Review of Resident #4's physician's orders revealed the resident was ordered the cholesterol medication atorvastatin 10 milligrams (mg) by mouth at bedtime, the supplement cyanocobalamin 1000 micrograms (mcg) by mouth daily, the blood pressure medication amlodipine besylate 10 mg by mouth daily, and the combination blood pressure medication hydrochlorothiazide and lisinopril 12.5 mg-20 mg by mouth daily on 04/03/24. On 04/16/24, Resident #4 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to implement nutritional interventions for a resident with significant weight loss in a timely manner. This affected one (Resident #20) of three residents reviewed for weight loss. The facility census was 113. Findings include: Review of the medical record for Resident #20 revealed an admission date of 02/29/20 with diagnoses including Alzheimer's disease, anemia, atherosclerotic heart disease of coronary artery, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #20 dated 02/27/24 revealed the resident was cognitively impaired and was dependent on staff assistance for eating, toileting, bathing, dressing, and transfers. Review of the care plan for Resident #20 dated 02/27/24 revealed the resident had a nutritional problem and was at risk for malnutrition related to unintentional weight changes, altered diets, and dysphagia. Interventions included the following: administer medications as ordered staff to monitor weight and make…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 record review, observation, staff interview, and policy review, the facility failed to ensure food was prepared in a manner to prevent potential contamination and spread of foodborne illness. This had the potential to affect all eight residents (#2, #3, #33, #37, #50, #53, #60, and #82) who received a pureed diet. The facility census was 113. Findings include: Observation on 07/12/23 at 11:18 A.M. revealed [NAME] #159 use her gloved hand to take four chicken breasts from a baking sheet, and placed them in a food processor, located directly next to the baking sheet, containing approximately ten additional chicken breasts. [NAME] #159 then reached on top of the steamer, located directly behind her, and obtained and donned a rubber oven mitt. [NAME] #159 pureed the chicken in the food processor, then removed the oven mitt, setting it on the counter. The arm of the oven mitt was observed sitting directly on top of two chicken breasts still remaining on the baking sheet. Interview on 07/12/23 at 11:20 A.M. with [NAME] #159 verified the arm of the oven mitt was resting directly…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-13 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interview, and record review, the facility failed to maintain Resident #62's room in a clean manner. This affected one (Resident #62) of six residents reviewed for homelike environment. The facility census was 113. Findings include: Record review for Resident #62 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, anxiety, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/21/23, revealed Resident #62 had mild cognitive impairment. Review of the progress note, dated 07/10/23, revealed Resident #62 had emesis two times on this day (07/10/23). Interview on 07/11/23 at 9:33 A.M. with Resident #62 revealed she was lying in bed watching television. Resident #62 stated she had vomited two times the previous evening on 07/10/23. Resident #62 stated she vomited in her sink and was concerned because she did not think staff had cleaned her sink out. Observation on 07/11/23 at 9:45 A.M. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 interview, and policy review, the facility failed to ensure orders from a wound clinic were implemented and followed for a resident with multiple diabetic wounds. This affected one (#70) of one resident reviewed for diabetic ulcers. The facility census was 113. Findings include: Review of Resident #70's medical record revealed Resident #70 was re-admitted to the facility on [DATE]. Diagnoses included morbid obesity due to excess calories, chronic diastolic (congestive) heart failure, chronic respiratory failure with hypoxia, gangrene, type II diabetes mellitus with diabetic chronic kidney disease, and end stage renal disease. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had moderate cognitive impairment. Resident #70 required extensive assistance of two staff for bed mobility, transfer, and toilet use. Review of the care plan revealed Resident #70 had venous/stasis ulcer to his bilateral feet/heels and right ankle…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Dcited before2023-07-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 interview, and policy review, the facility failed to ensure a new unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) was measured upon identification. This affected one (#13) of four residents reviewed for pressure ulcers. The facility identified nine residents with pressure ulcers. The facility census was 113. Findings include: Review of the medical record for Resident #13 revealed an admission date of 03/27/23. Diagnoses included pulmonary embolism, major depressive disorder, fibromyalgia, and adjustment disorder with mixed anxiety and depressed mood. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of a nursing progress note dated 06/09/23 revealed an unstageable pressure area was observed on Resident #13's heel. The physician…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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, observations, staff interviews, and policy review, the facility failed to ensure the residents who were at risk for falling had their care-planned and/or physician ordered fall interventions in place. This affected three (#13, #42, and #62) of five residents reviewed for falls. The facility census was 113. Findings include: 1. Review of Resident #13's medical record revealed an admission date of 03/27/23. Diagnoses included pulmonary embolism, insomnia, major depressive disorder, and adjustment disorder with mixed anxiety and depressed mood. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of the plan of care dated 05/03/23 revealed Resident #13 was at risk for falls related to gait/balance problems, side effects of medications, and incontinence. Interventions included anti-rollback to Resident #13's wheelchair.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-15 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, review of Self-Reported Incidents, and review of facility policy, the facility failed to report allegations of verbal, sexual and physical abuse to the Survey State Agency, the Ohio Department of Health (ODH). This affected three (Residents #58, #76 and #106) of five residents reviewed for abuse. The facility census was 134. Findings include: 1. Review of record revealed Resident #58 was admitted on [DATE] with a diagnoses which included end stage renal disease. Review of the Minimum Data Set (MDS) assessment, dated 07/03/19, revealed the resident was cognitively impaired and was coded as negative for behavioral symptoms. Review of record revealed Resident #45 was admitted on [DATE] with diagnoses which included congestive heart failure. Review of the MDS assessment, dated 07/01/19, revealed the resident was cognitively intact, required supervision with activities of daily living, and was coded as negative for behavioral symptoms. Review of the progress notes…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-15 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview and review of facility policy, the facility failed to thoroughly investigate allegations of verbal, sexual and physical abuse to the Ohio Department of Health (ODH). This affected three (Residents #58, #76 and #106) of five residents reviewed for abuse. The census was 134. Findings include: 1. Review of record revealed Resident #58 was admitted on [DATE] with a diagnoses which included end stage renal disease. Review of the Minimum Data Set (MDS) assessment, dated 07/03/19, revealed the resident was cognitively impaired and was coded as negative for behavioral symptoms. Review of record revealed Resident #45 was admitted on [DATE] with diagnoses which included congestive heart failure. Review of the MDS assessment, dated 07/01/19, revealed the resident was cognitively intact, required supervision with activities of daily living, and was coded as negative for behavioral symptoms. Review of progress notes for Resident #45, dated 08/05/19, revealed the 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-08-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 observation, record review and staff interviews, the facility failed to ensure pressure reduction devices were in place. This affected one (Resident #94) of four reviewed for pressure injury. The facility identified all 134 residents residing in the facility were receiving preventative skin care. Findings include: Review of Resident #94's medical record revealed an admit date of 06/16/19 with diagnoses including urinary tract infection, obstructive uropathy, dementia and malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 07/19/19, revealed the resident had severe cognitive impairment, required extensive assistance of two staff members for bed mobility and transfers. Review of the physician orders, dated 07/19/19 revealed Prevalon boots (aid in pressure reduction) to be worn. Review of the [NAME] (care plan interventions for state tested nurse assistants) dated 08/09/19 indicated - offload heels with pillows as tolerated. The [NAME] was silent to Prevalon boots ordered by the physician.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-08-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 review, observations, and staff interviews, the facility failed to use safety device equipment as care planned to prevent falls. This affected two (Residents #58 and #94) of five residents reviewed for falls. The in-house facility census was 134. Findings include: 1. Record review for Resident #58 revealed the resident was admitted to the facility on [DATE]. Diagnoses included syncope, hyperglycemia, diabetes mellitus, atrial fibrillation, hypertension, hemiplegia, chronic obstructive pulmonary disease, arthropathy, glaucoma and altered mental status. Review of the quarterly Minimum Data Set assessment, dated 07/03/19, revealed Resident #58 has mild to moderate cognitive deficits and required extensive assistance with activities of daily living. Review of the care plan, dated 04/11/19, revealed Resident #58 was at risk for falls related to gait/balance problems, side effects of medications, impaired mobility, new environment, hemiparesis, altered mental status, incontinence and blind. An…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation and staff interview, the facility failed to label resident oxygen tubing and humidification bottles with the date it was initiated. This affected one (Resident #92) of three residents reviewed for respiratory care. The facility identified 38 residents on oxygen use. The facility census was 134. Findings include: Record review for Resident #92 revealed an admission date of 07/10/19 with diagnoses which included chronic respiratory failure. Review of the Minimum Data Set (MDS) assessment, dated 08/05/19, revealed the resident was cognitively intact and required extensive assistance of two staff with activities of daily living. Review of the resident's physician orders, dated 07/29/19, revealed an order the resident may use oxygen at two liters per minute per nasal cannula as needed for shortness of breath. Observation of Resident #92 on 08/12/19 at 9:54 A.M. revealed the resident had oxygen in place at two liters per nasal cannula with humidification. The oxygen tubing and the humidification bottle was undated. Interview with Licensed Practical…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-15 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, dialysis staff interview and resident and staff interview, the facility failed to assess the resident's weight before providing peritoneal dialysis and failed to ensure medication was given per physician's order. This affected one (Resident #9) of one resident reviewed for peritoneal dialysis. The facility identified 10 residents on dialysis services. Findings include: Review of Resident #9's medical record revealed an admission date of 02/08/19. Diagnoses included diabetes mellitus, anemia, congestive heart failure and end stage renal disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/05/19, the resident's cognition was intact and there were no refusal of care or behaviors. The MDS also revealed assist of one was required for bathing, toileting, but supervision only for other activities of daily living. Review of the care plan, dated 02/08/19, had a focus for peritoneal dialysis and interventions that included administer medications as indicated, monitor for signs/symptoms of fluid overload including increased weight. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-15 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 and staff interview, the facility failed to administer physician ordered intravenous antibiotics. This affected one (Resident #71) of three residents reviewed for infections and had potential to affect three residents the facility identified as receiving intravenous antibiotics. The facility census was 134. Findings include: Review of Resident #71's medical record revealed an admit date of 06/10/19. Diagnoses included stroke, diabetes, anemia, urinary tract infection, heart failure, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/29/19, revealed the resident had intact cognition. Review of the resident's care plan, dated 07/30/19, revealed a focus of a blood infection with interventions including to administer antibiotics per physician orders. Review of the resident's Medication Administration Record (MAR), dated 08/01/19, revealed the physician ordered for Vancomycin (antibiotic) 500 milligrams every other day. Review of the MAR indicated Vancomycin was not administered on 08/03/19 and stated see the notes, on 08/05/19 it…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility policy review, the facility failed to provide a stop date on psychotropic medications. This affected two (Resident #45 and #90) of seven residents reviewed for unnecessary medications. The facility in-house census was 134. Findings include: 1. Record review for Resident #90 on 08/14/19 revealed Resident #90 was admitted on [DATE]. Diagnoses included anxiety and depression. Review of the admission Minimum Data Set (MDS) assessment, dated 07/17/19, revealed Resident #90 has severe cognitive deficits. Review of the physician order, dated 07/16/19 revealed to give Alprazolam (anti-anxiety) 0.25 milligrams (mg.) every eight hours as needed for anxiety with no end date. Review of the Medication Administration Review (MAR), dated 07/2019, revealed Alprazolam 0.25 mg. was given on the following dates 07/17/19, 07/18/19, 07/19/19, 07/20/19, 07/21/19, 07/23/19, 07/24/19, 07/25/19, 07/26/19, 07/28/19 and 07/30/19. Review of the MAR dated for 08/2019 revealed 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-08-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 record review, observation, staff interview, and review of facility policy, the facility failed to discard expired medications and failed to appropriately store medications regarding refrigeration. This affected three of four medication carts observed. The facility had eight medication carts. This affected three residents (Residents #57, #90 and #320) observed to have expired and/or improperly stored medications stored in the medication carts. The facility census was 134. Findings include: 1. Record review for Resident #57 revealed an admission date of 03/04/19 with a diagnosis of diabetes. Review of the physician orders, dated 06/18/19, revealed an order for Lantus insulin to be given by subcutaneous injection 20 units every evening. Observation of the Lantus insulin pen in the medication cart for Resident #57 on 08/14/19 at 2:39 P.M. with Registered Nurse (RN) #280 revealed the insulin had marked with an expiration date of 08/13/19. Interview on 08/14/19 at 2:39 P.M. with RN #280 confirmed the Lantus insulin pen for Resident #57 was expired and should be discarded. 2.…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-15 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and resident and staff interview, the facility failed to offer and arrange for dental consultation for one (Resident #45) of four residents reviewed for dental concerns. The facility census was 134. Findings include: Record review for Resident #45 revealed the resident was admitted on [DATE] with diagnoses which included congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 07/01/19, revealed the resident was cognitively intact and was not coded for dental concerns. Review of the care plan, initiated on 01/25/19, revealed the care plan was silent regarding resident's dental status or any dental needs. Review of the physician's order, dated 01/25/19, revealed an order that resident may be seen by the dentist. Review of the record for Resident #45 revealed no written record of consent or declination of dental visits. Interview and observation of Resident #45 on 8/13/19 at 3:36 P.M. revealed the resident had multiple missing teeth and several teeth…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to follow infection control measures for a resident's urinary catheter. This affected one (Resident #94) of three residents reviewed for urinary catheters. The facility identified three residents with urinary catheters. Findings include: Review of Resident #94's medical record revealed an admit date of 6/16/19 with diagnoses including urinary tract infection, prostate enlargement and obstructive uropathy. Review of the Minimum Data Set (MDS) assessment, dated 07/19/19, revealed the resident had severe cognitive impairment. Review of the state tested nursing aide [NAME], dated 08/09/19, revealed to position the catheter bag and tubing below the level of the bladder and off of the floor. Observation on 08/12/19 at 3:07 P.M. of Resident #9 revealed he was lying in bed and the resident's urinary catheter bag was lying on the floor. Interview on 08/12/19 at 3:15 P.M. with Licensed Practical Nurse #160 and Unit Manager, Registered Nurse (RN)…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$17,345 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $17,345 — penalty dated 2025-07-01
  • Medicare payment denial — starting 2024-05-16 for 20 days

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.

Part of a chain

This home belongs to CARESPRING — 16 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 54.0-2.0 vs chain
Health inspection 3 of 53.6-0.6 vs chain
Staffing 1 of 52.4-1.4 vs chain
Quality measures 4 of 54.6-0.6 vs chain
The other 15 homes this chain runs (chain average 4.0★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
CARESPRING HEALTH CARE HOLDINGS LPOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 10/01/2013
BARRY N BORTZ 06042009 TROrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST72%since 10/01/2013
BORTZ FAMILY TRUST/KEY BANK TRUSTEEOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST9%since 10/01/2013
EPPERS, DAVIDIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER15%since 08/01/2012
GENDELMAN, ARTHURIndividualW-2 MANAGING EMPLOYEEsince 01/01/2024
HOMAN, ROSSIndividualW-2 MANAGING EMPLOYEEsince 10/26/2023
CHIRUMBOLO, CHRISTOPHERIndividualCORPORATE OFFICERsince 09/01/2016
CARESPRING HEALTH CARE MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2009

CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$13.5M
Net patient revenuemost recent cost report
-20.3%
Operating marginrevenue minus expenses
$832K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 18%Medicare 7%Other / private 75%

This home reported $832K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$406per resident / day
operating cost
$12,343per month
≈ monthly operating cost
$338per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Ohio
$9,186/mo
Nursing home (semi-private)
$10,389/mo
Nursing home (private)
$6,103/mo
Assisted living

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 366380. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-01, 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.

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