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Montgomery Care Center

7777 Cooper Road, Cincinnati, OH 45242 · For profit - Limited Liability company · 99 certified beds · (513) 793-5092 Medicare & Medicaid certified

Call the home — (513) 793-5092 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0567)1 actual-harm citation
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)
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0567)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (67%) 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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Montgomery Rd · (513) 936-4510 · Call to confirm hours
Pharmacy
CVS Photo0.3 mi
9546 Montgomery Rd · (513) 793-4451 · Call to confirm hours
Grocery
9731 Montgomery Rd · (513) 891-9280 · Call to confirm hours
Park
Swaim Park, 7650 Cooper Rd · (513) 891-2424 · Typically dawn to dusk
Place of worship

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 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 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.

Overall rating2★
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 increased9.1%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight5.9%6.2%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.4%0.4%2.0%typical for the state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms47.3%30.1%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.4%0.1%0.1%worse
Long-stay residents with falls causing major injury4.2%3.2%3.3%worse
Long-stay residents whose ability to walk worsened16.6%6.1%16.1%typical
Long-stay residents on antianxiety or hypnotic medication32.3%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine95.2%94.5%95.3%typical
Long-stay residents with pressure ulcers4.9%3.4%4.7%typical
Long-stay residents with worsening bladder/bowel control16.1%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table14.5%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication2.1%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine40.8%75.6%79.4%worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

0.23U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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

0.44
RN hours/ resident / day
1.13
LPN hours/ resident / day
1.75
Aide hours/ resident / day
3.31
Total nurse hours/ resident / day
0.29
RN hoursweekends
66.7%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 99 beds and averages 68.6 residents a day — about 69% occupied, or roughly 30 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.75 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.78 hrs/resident/day on weekends vs 3.53 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.50 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 67% is well above 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

7
deficiencies at the latest standard inspection (2024-12-19)
8
at the previous standard inspection (2022-03-02)

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.

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · G2019-03-12 · 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 2. Review of Resident #33's record revealed he was admitted to the facility on [DATE]. Diagnoses included disorders of lung, dementia with behavioral disturbance, phobic anxiety disorders, chronic kidney disease, alcohol dependence in remission, heat syncope, muscle weakness, and wasting and atrophy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/20/19, revealed the resident had severe cognitive impairment and he required supervision with dressing and personal hygiene and was independent with eating, toileting, bed mobility and transfers. A review of the care plan for Resident #33 revealed he had the potential for injury related to smoking and the facility was to secure his cigarettes and lighter at the nurse's station. Review of the smoking assessment, dated 11/14/18, documented the need for supervision during smoking, the use of a smoking apron and the need for the facility to store his lighter and cigarettes. During an interview with the Director of Nursing on 03/06/19 at 2:18 P.M., she…

    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 · E2025-08-12 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations, interview, and policy review, the facility failed to ensure showers were properly maintained. This affected 12 residents (#6, #8, #10, #11, #13, #14, #20, #21, #23, #26, #30, and #33) identified by the facility that utilized the shower room. The facility census was 64.Findings include:Observations on 08/11/25 at 8:42 A.M. of the shower room on the east unit revealed there were two shower areas. One of the showers had a leaking shower head that sprayed water in various directions when the water was turned on, and the shower handle in the other shower was loose and not secured to the wall.Interview on 08/11/25 at 8:44 A.M. with Maintenance Director (MD) #112 verified the findings at the time of the observations.Review of the facility policy titled, Quality of Life - Homelike Environment, revised 05/2017, revealed residents would be provided with a safe, clean, comfortable and homelike environment.This deficiency represents non-compliance investigated under Complaint Number 2566252 and Complaint Number 2565845.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-19 · tag F0687 — failed to care for feet properly — pattern
    Provide appropriate foot care.
    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 and resident interviews, the facility failed to ensure residents received routine podiatry care. This affected four (Residents #20, #21, #2 and #14) of the four residents reviewed for podiatry services. The facility census was 60. Findings include: 1) Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of cerebral infarction with dominant left side hemiplegia and hemiparesis, vascular dementia and chronic kidney disease. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #20 had moderately impaired cognition, range of motion impairment on left upper and lower extremities and was frequently incontinent of bowel and bladder. Review of Resident #20's Activities of Daily Living (ADL) care plan dated 12/12/24 revealed Resident #20 had a self-care performance deficit. Interventions included total assistance with personal hygiene daily and as needed. Observation of wound treatment…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-19 · tag F0761 — failed to label and store drugs safely — pattern
    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 review of the medical record, observation, interviews, and policy review, the facility failed to ensure eye drops were labeled with open date. This affected two (#06 and #19) of the 14 residents with ordered eye drops. The facility also failed to timely dispose of narcotics for residents who were no longer in the facility. This affected two (#213 and #214) residents of the nine residents with narcotics. The facility census was 60. Findings include: 1) Review of the medical record for Resident #06 revealed an admission date of 12/29/21. Diagnoses included glaucoma, Alzheimer's disease, and type two diabetes mellitus (DM II). Review of the physician order dated 02/24/22 revealed Resident #06 was ordered Brimonidine Tartrate 0.2 percent solution, instill one drop in both eyes three times a day related to glaucoma. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #06 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0567 — failed to protect residents' money held by the home — isolated
    Honor the resident's right to manage his or her financial affairs.
    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 obtain authorization to manage resident funds. This affected two (#23 and #34) out of five residents reviewed for resident funds. The facility census was 60. Findings include: 1) Review of the medical record for Resident #23 revealed an admission date of 07/24/23. Diagnoses included flaccid hemiplegia affecting left non-dominant side, chronic obstructive pulmonary disease, type two diabetes mellitus without complications, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, anemia, major depressive disorder, atherosclerotic heart disease of native coronary artery with other forms of angina pectoris, hyperlipidemia, anxiety disorder, vascular dementia, chronic kidney disease stage three, atrial fibrillation, congestive heart failure, iron deficiency, fibromyalgia, cerebral edema, and vitamin d deficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and policy review, the facility failed to ensure accuracy of assessments related to hearing. This affected one (#03) of one resident reviewed for communication. The facility census was 60. Findings include: Review of the medical record for Resident #03 revealed an admission date of 01/24/24. Diagnoses included unspecified sequelae of unspecified cerebrovascular disease, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, hypothyroidism, spastic hemiplegia affecting unspecified side, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side, major depressive disorder, localized edema, rhabdomyolysis, syncope and collapse, acute kidney failure, neuromuscular dysfunction of bladder, pure hypercholesterolemia, hypertension, and dysphagia. Review of the Minimum Data Set (MDS) assessments dated 01/30/24, 05/01/24 and 11/01/24, revealed Resident #03 was cognitively intact, had minimal difficulty with hearing and used hearing aids. Interview on 12/17/24 at 8:56 A.M.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-19 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 review of the medical record, staff interviews, and policy review, the facility failed to ensure care conferences were completed quarterly for residents. This affected two (#14 and #20) of three residents reviewed for care conferences. The facility census was 60. Findings include: 1) Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses include cerebral infarction with dominant left side hemiplegia and hemiparesis, vascular dementia and chronic kidney disease. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed Resident #20 had moderately impaired cognition. Review of the documentation provided by the Administrator revealed Resident #20 was offered care conferences in the first quarter (January, February and March 2024) and second quarter (April, May and June 2024) of 2024; however, the resident declined the need. A care conference was conducted for Resident #20 in the fourth quarter (October, November and December 2024) 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0685 — isolated
    Assist 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, staff and resident interviews, and policy review, the facility failed to timely arrange for audiology services. This affected one (#03) of the one resident reviewed for communication. The facility census was 60. Findings include: Review of the medical record for Resident #03 revealed an admission date of 01/24/24. Diagnoses included unspecified sequelae of unspecified cerebrovascular disease, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, hypothyroidism, spastic hemiplegia affecting unspecified side, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side, major depressive disorder, localized edema, rhabdomyolysis, syncope and collapse, acute kidney failure, neuromuscular dysfunction of bladder, pure hypercholesterolemia, hypertension, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #03 was cognitively intact. The assessment also indicated…

    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 · D2024-12-19 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, observations, interviews, and policy review, the facility failed to timely change oxygen tubing per physician orders. This affected one (#14) resident of six residents with oxygen therapy. The facility census was 60. Findings include: Review of the medical record for Resident #14 revealed an admission date of 10/18/22. Diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, and type two diabetes. Review of the care plan dated 11/01/22, revealed Resident #14 had oxygen therapy related to asthma, COPD, and shortness of breath (SOB). Interventions included check oxygen saturation as needed for SOB, encourage or assist with ambulation as indicated, and give medications as ordered by physician. Review of the physician order dated 06/27/24, revealed Resident #14 was ordered may use supplemental oxygen as needed (PRN) two liters per minute (LPM) via nasal cannula every shift for maintaining oxygen saturation greater than 90 percent (%) 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-20 · 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 medical record review, observation, resident and staff interview, and review of the facility policy, the facility failed to keep a resident's room clean and sanitary. This affected one (Resident #12) of three residents reviewed for environment. The facility census was 57. Findings include: Review of the medical record for Resident #12 revealed an admission date 03/21/24. Diagnosis included anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact. Interview on 06/20/24 at 10:35 A.M. with Resident #12 stated the housekeeping staff does not wipe down the furniture in her room. Resident #12 stated they do not sweep under her bed, or corners in the room. Resident #12 stated she took out her own trash from her room because it does not get taken care of. Resident #12 stated her toilet was disgusting, dirty, smells, and had urine ring around the toilet. Observation on 06/20/24 at 10:40 A.M. with Resident #12's room revealed all three of her…

    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 · F2022-03-02 · 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 interviews, record review, and review of the facility policies, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. This had the potential to affect 69 of 70 residents residing in the facility, excluding Resident #50 who received enteral feedings and nothing by mouth. Findings include: 1. An initial tour of the kitchen was conducted on 02/14/22 at 9:45 A.M. with [NAME] #22. While touring the kitchen, the following was observed: 1a. The free-standing walk-in freezer located outside of the building with [NAME] #22 felt very warm and observation revealed a non-functioning thermometer sitting on the shelf. Continued observation revealed the ice cream was completely liquefied, the tater tots, French fries and all vegetables were very soft to touch. [NAME] #22 stated she last got something from the freezer at 5:45 A.M. and everything seemed to be working normally. [NAME] #22 verified the freezer was not working, non-functioning thermometer and numerous food items were thawed…

    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
Show the remaining 17 citations
  • Potential for harm · Ecited before2022-03-02 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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

    Based on observations, resident and staff interviews, review of the facilities policy, the facility failed to provide a safe, clean comfortable and homelike environment. This affected five (Residents #05, #38, #41, #422, and #423) of 18 residents reviewed for a homelike environment. The facility census was 70. Findings include: During interview with Residents #05 and #41 on 02/15/22 at 4:01 P.M. revealed the long wall where the resident's dressers and televisions were located revealed there were large areas of the drywall damaged. Observations also revealed the wall where the window was located had numerous damaged areas of drywall and the wall behind the resident's bed had large areas of damaged drywall. Resident #41 stated the walls had been in disrepair for long time. During observation of Residents #422 and #423's room on 02/15/22 at 4:30 P.M. revealed large areas of mold on the window blinds and the toilet was unsecured from the flange and moved side to side. The window blinds were directly over the heating air condition (HVAC) unit in the wall. Both residents were ambulatory…

    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 before2022-03-02 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 record review, observation, staff interview and review of the facility's policy, the facility failed to treat residents with respect and dignity. This affected two (Resident #29 and #34) of 18 residents reviewed for dignity and respect. The facility census was 70. Findings include: 1. Review of the medical record for Resident #29, revealed an admission date of 12/02/21. Diagnoses included Parkinson's disease, schizophrenia, epilepsy, and lack of coordination. Review of the Minimum Data Set (MDS) assessment, dated 12/21/21, revealed Resident #29 was cognitively intact and required extensive or limited assistance with activities of daily livings (ADLs). Review of the activities interview for daily and activity preferences dated 05/27/20 revealed Resident #29 noted doing things in groups of people was very important to him. Observation of the group activities on 02/16/22 at 3:15 P.M. revealed 11 residents were in a group activity located in the [NAME] common area. During the observation, Activities Director (AD) #06 very loudly stated you don't talk to me that way to 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-02 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure advance directives were accurate. This affected two (#53 and #325) of 18 residents reviewed for advance directives. The facility census was 70. Findings include: 1. Review of the medical record for Resident #53 revealed an admission date of 05/07/19. Diagnoses included chronic obstructive pulmonary disease, hemiplegia, type two diabetes mellitus without complications, transient cerebral ischemic attack, peripheral vascular disease, epilepsy, chronic pain syndrome, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/11/22, revealed Resident #53 had moderately impaired cognition. Review of the current physician orders in the electronic health record revealed an order for do not resuscitate comfort care (DNRCC), dated 04/22/21. Review of the plan of care, revised 06/09/21, revealed the resident had a code status of DNRCC. Review of the resident's paper health record revealed 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-02 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, review of the facility's policy, and staff interview, the facility failed to complete a discharge care plan for a resident. This affected one (Resident #324) of three residents reviewed for discharge care planning. The facility census was 70. Findings Include: Record review for Resident #324 revealed an admission date of 01/27/22. Diagnoses included Coronavirus 19 (COVID-19), diabetes mellitus type II, local infection of the skin and subcutaneous tissue, gangrene, cutaneous abscess of right foot, essential primary hypertension, hyperlipidemia, obesity, methicillin susceptible staphylococcus aureus, and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 02/03/22, revealed Resident #324 had intact cognition. Review of the Resident #324's care plans revealed he did not have a care plan in place regarding discharge planning. Interview on 02/15/22 at 2:55 P.M. with MDS Nurse #26 confirmed Resident #324 did not have a discharge care plan in place. MDS Nurse #26 confirmed the discharge planning begins upon admission…

    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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-02 · 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 medical record review, staff interview, and review of the facility's policy, the facility failed to ensure medications were administered as ordered. This affected two (#53 and #324) of five residents reviewed for unnecessary medications. The facility census was 70. Findings include: 1. Record review for Resident #324 revealed an admission date of 01/27/22. His diagnoses included diabetes mellitus II, local infection of the skin and subcutaneous tissue, gangrene, cutaneous abscess of right foot, methicillin susceptible staphylococcus aureus, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 02/03/22, revealed Resident #324 had intact cognition. Review of the Medication Administration Review (MAR) dated February 2022 revealed the following information regarding missed dosages of medication for Resident #324: • Ceftriaxone sodium solution reconstituted (antibiotic) two gram intravenously one time a day related to cutaneous abscess of right foot until 02/17/22. One dose was missed on 02/11/22. A note was written in the progress notes that…

    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 · D2022-03-02 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, record review, and review of the facility's policy, the facility failed to provide food that was served at a safe and appetizing temperature. This had the potential to affect the two residents (#18 and #426) who were on a pureed diet. The facility census was 70. Findings included: During observations of the lunch pre-service food temperatures on 02/16/22 at 11:28 A.M. revealed [NAME] #22 checked the puree chicken and recorded a holding temperature of 108 degrees Fahrenheit (F) on the Daily Food Temp Log. Review of the completed temperature log with [NAME] #22, immediately as she completed temperature checks, [NAME] #22 confirmed she received and recorded the temperature of 108 degrees F for the puree chicken. [NAME] #22 stated Residents #18 and #426 were only two residents on a puree diet. During continued observations of the kitchen and follow-up interview with [NAME] #22 on 02/16/22 at 12:20 P.M. and review of the lunch temperature logs, the log appeared to have been changed to show the chicken was 188 degrees F. [NAME] #22 again confirmed…

    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 · D2022-03-02 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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, review of the facility's policy, observations and resident and staff interviews, the facility failed to a resident received the appropriate diet for her food allergy. This affected one (#322) of 18 residents reviewed for food quality. The facility census was 70. Findings include: Review of Resident #322's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included celiac disease. Allergies listed included gluten. Review of the physician orders, dated 02/06/22, revealed a diet order for a heart healthy (cardiac) diet, regular texture, thin consistency. Observations on 02/14/22 at 12:20 P.M. revealed a Styrofoam food container on a tray for Resident #322. A piece of toast was sticking out of the container. Interview on 02/14/22 at 12:24 P.M. with Resident #322 stated she couldn't eat a lot of the food that was served to her. She stated the kitchen provides the incorrect diet to her and explained she was gluten intolerant. She stated the kitchen has been…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-03-12 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff interviews, the facility failed to ensure cognitive impaired residents were treated in a dignified manner while assisting them with eating their lunch. This affected five (Resident #14, #21, #27, #50 and #65) of seven residents observed during lunch in the westside dining room. The facility census was 81. Findings include: 1. Review of medical record revealed Resident #14 was admitted to the facility on [DATE]. Diagnoses included heart failure and cerebrovascular accident transient. Review of the annual Minimum Data Set (MDS) assessment, dated 12/15/18, revealed Resident #14 had severely impaired cognitive deficits and required total dependence with activities of daily living. Review of medical record revealed Resident #21 was admitted to the facility on [DATE]. Diagnoses included dementia and depression. Review of the quarterly MDS assessment, dated 01/01/19, revealed Resident #21 had moderately impaired cognitive deficits and required extensive assistance with…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-03-12 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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

    Based on observations and resident and staff interviews, the facility failed to maintain resident's room environment in a clean, sanitary and comfortable manner. This affected five (Resident #29, #34, #37, #53 and #231) of the 24 residents interviewed for environment. The facility census was 81. Findings include: 1. On 03/04/19 at 3:49 P.M., an observation of Resident #29 and #37's bathroom revealed the bathroom floors were sticky, underneath the toilet lid, towards the back was not clean, and a hole was observed on the wall in the resident's room between the two televisions. 2. On 03/04/19 at 4:51 P.M., an observation of Resident #34's bathroom revealed the bathroom toilet was stained with a brown ring around the inside of the toilet bowl. Interview on 03/04/19 at 5:00 P.M., revealed Resident #34 reported she hated the look of the toilet. She stated a person should not have to live like this. 3. On 03/04/19 at 6:18 P.M., an observation of Resident #231's room revealed the room was not swept and mopped. The trash can have no liner in it and Resident #231 was spitting in the trash…

    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 · Ecited before2019-03-12 · tag F0761 — failed to label and store drugs safely — pattern
    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 — the official record, unedited, may be distressing

    Based on observation, interviews, and facility policy review, the facility failed to ensure open vials of medication were properly labeled. This had the potential to affect 34 residents residing on the east wing. The facility census was 81. Findings include: Observation on 03/07/19 at 8:17 A.M. of the east wing medication room's medication refrigerator revealed two open vials of Sequiris Influenza vaccine with an expiration date of 06/30/19 which were not labeled with the date they were opened. In an interview on 03/07/19 at 8:17 A.M., Licensed Practical Nurse (LPN) #112 verified the two open vials of influenza vaccine were not labeled with the date they were opened. In an interview on 03/07/19 at 8:30 A.M., Regional Clinical Coordinator (RCC) #64 verified the two open vials of influenza vaccine were not labeled with the date they were opened and the facility policy stated to date them with the date opened. Review of the facility policy, titled Storage of Medications, dated 12/2018, revealed it did not address the labeling of opened medications.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-03-12 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, review of facility policy, review of manufacturer guidelines and staff interviews, the facility also failed to ensure glucometers used for multiple residents were sanitized properly. This had the potential to affect 18 (#3, #8, #11, #31, #34, #35, #39, #44, #49, #59, #63, #64, #70, #71, #72, #73, #74, and #378) of 81 residents within the facility who required the use of a glucometer. Findings include: Observation on 03/05/19 at 7:36 A.M. of Licensed Practical Nurse (LPN) #1 revealed LPN #1 laid a glove box and a basket containing gauze pads, alcohol swabs, and lancets directly on Resident #3's bed. Upon obtaining Resident #3's blood sugar result, LPN #1 laid the contaminated glucometer in the basket with the clean glucometer supplies. LPN #1 then proceeded to Resident #13's room without washing or sanitizing her hands and without sanitizing the glucometer and proceeded to setup the materials to obtain Resident #13's blood sugar. With surveyor intervention, the LPN #1 was stopped from proceeding with the collection and asked LPN #1 to step outside the room. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-03-12 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, and record reviews, the facility failed to protect the health information of residents. This affected one resident (#40) of 81 residents observed during the annual survey. Findings include: Observation on 03/07/19 at 8:26 A.M. revealed the laptop on top of the east wing medication cart for the far hallway was open and the medical record for Resident #40 was visible and accessible. Resident #40's photograph was located in the top left corner of the laptop and his medication administration record was exposed. There were three residents in the dining area of the east wing, and several residents ambulating in the hallway near the medication cart. Interview on 03/07/19 at 8:30 A.M. with Activity Director (AD) #122 verified that the laptop was open on the medication cart and Resident #40's photograph and electronic health record (EHR) were visible and accessible. Interview on 03/07/19 at 8:35 A.M. with Licensed Practical Nurse (LPN) #126 verified she was the nurse assigned to that medication cart and that she had accessed Resident #40's EHR on 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-03-12 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy and staff interview, the facility failed to provide a bed hold notice to two (Resident #34 and #74) of four residents reviewed for hospitalization. This had the potential to affect all 81 residents residing in the facility. Findings include: 1. Review of the record for Resident #34 revealed she was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, congestive heart failure and chronic respiratory failure. Review of the admission Minimum Data Set (MDS) assessment, dated 01/07/19, revealed the resident had moderate cognitive impairment. Review of the progress notes for Resident #34 revealed she was sent to the hospital on [DATE] due to chest pain and shortness of breath and returned to the facility on [DATE]. The resident's record was silent for any bed hold notice to the resident and/or resident's representative. During an interview with Corporate Registered Nurse #64 on 03/07/19 at 1:05 P.M., he verified no bed hold…

    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 · D2019-03-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to develop a comprehensive resident-centered care plan for Residents #11. This affected one (Resident #11) of 18 residents whose care plans were reviewed. The facility census was 81. Findings include: Record review of Resident #11 revealed he was admitted initially to the facility on [DATE] with recent readmission of 12/05/18. Diagnoses included glaucoma and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 12/13/18, revealed the resident was cognitively intact and the resident had adequate vision. Review of physician orders revealed the resident was receiving Latanoprost 0.005% eye drops for glaucoma. Review of Resident #11's care plan revealed it was silent to resident's glaucoma and eye drops related medications for glaucoma. Interview on 03/07/19 at 8:18 A.M. with Regional Clinical Consultant (RCC) #64 verified the resident's care plan was not person centered and does not reflect that he has glaucoma.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-03-12 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 and staff interview, the facility failed to timely revise the care plan for Resident #279 following a fall. This affected one (Resident #279) of one resident reviewed for falls. The facility census was 81. Findings include: Review of the record for Resident #279 revealed she was admitted to the facility on [DATE]. Diagnoses included sepsis, chronic kidney disease and urinary tract infection. Review of the admission Minimum Data Set (MDS) assessment, dated 03/07/19, revealed she was severely impaired in decision making and was totally dependent on staff for bed mobility and transfers. Review of the nurse's progress note, dated 03/02/19, revealed Resident #279 was found on the floor in her room next to her bed on 03/01/19 at 7:58 P.M. The resident was noted to have a laceration to her nose and there was blood on the resident's face and on the floor and the resident was sent to the hospital emergency room. Another nurse's progress note, dated 03/02/19, revealed Resident #279 returned 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-03-12 · 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 record review, observation and staff interview, the facility failed to follow the hospital discharge instructions for removing sutures. This affected one (Resident #279) of one resident reviewed for falls. The facility census was 81. Findings include: Review of Resident #279's record revealed the resident was admitted to the facility on [DATE]. Diagnoses included sepsis, diabetes mellitus, chronic kidney disease, dementia, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 03/07/19, revealed the resident was cognitively impaired and was totally dependent on two persons assistance for bed mobility. Review of the nurse's progress note, dated 03/02/19, revealed Resident #279 was found on the floor in her room next to her bed on 03/01/19 at 7:58 P.M. The resident was noted to have a laceration to her nose and there was blood on the resident's face and on the floor and the resident was sent to the hospital emergency room. Another nurse's progress note, dated 03/02/19, revealed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-03-12 · 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

    Based on resident and staff interviews and record reviews, the facility failed to ensure routine dental care and dentures were provided for residents. This affected one (Resident #47) of one residents reviewed for dental. The facility census was 81. Findings include: Review of the medical record for Resident #47 revealed an admission date of 02/12/18. Diagnoses included chronic kidney disease, vascular dementia and dementia. Review of the annual Minimum Data Set (MDS) assessment, dated 07/10/1,9 revealed the resident had moderate cognitive impairment with behaviors of inattention, disorganized thinking, altered level of consciousness and there were no dental issues coded positively within the assessment for Resident #47. Review of Resident #47's physician orders, for 02/2019, revealed an order for a dental consult as necessary. Review of Resident #47's care plan, dated 02/12/18, revealed a focus of potential for or altered dental status related to poor oral hygiene with interventions of assistance with oral care as needed, notification of charge nurse of any chewing problems or…

    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

“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

No federal fines in the current CMS record.

Part of a chain

This home belongs to CARECORE HEALTH — 10 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 3 of 52.1+0.9 vs chain
Health inspection 3 of 51.8+1.2 vs chain
Staffing 2 of 51.7+0.3 vs chain
Quality measures 4 of 54.3-0.3 vs chain
The other 9 homes this chain runs (chain average 2.1★, 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 / managerTypeRoleSince
CUSTOMERS BANKOrganization5% OR GREATER MORTGAGE INTERESTsince 08/14/2020
HERTANU, CHAIMIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2017
HERTANU, JOSEPHIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2017
CARECORE HEALTH LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2017
KURANGA, ABRAHAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2025
LAGHAIE, EITANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2017
FASTEN HALBERSTAM LLPOrganizationADP OF THE SNFsince 08/01/2017
MONTGOMERY AT CARECORE LLCOrganizationADP OF THE SNFsince 08/01/2017

CMS files one row per role, so the 18 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$6.6M
Net patient revenuemost recent cost report
-10.6%
Operating marginrevenue minus expenses
$720K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 20%Medicare 2%Other / private 79%

This home reported $720K 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

$318per resident / day
operating cost
$9,668per month
≈ monthly operating cost
$287per 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 365327. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-19, 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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