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Scarlet Oaks Nursing And Rehabilitation Center

440 Lafayette Avenue, Cincinnati, OH 45220 · For profit - Limited Liability company · 70 certified beds · (513) 861-0400 Medicare & Medicaid certified

Call the home — (513) 861-0400 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jan 2025Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

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 its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • 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
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
227 Greendale Ave · (513) 403-4032 · Call to confirm hours
Pharmacy
371 Ludlow Ave · (513) 281-4475 · Call to confirm hours
Grocery
Kroger0.7 mi
4777 Kenard Ave · (513) 681-7650 · Call to confirm hours
Park
700 Lafayette Ave · (513) 357-2604 · 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 3 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 1 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 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
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 increased7.9%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight10.1%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.2%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.3%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms3.6%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 injury2.1%3.2%3.3%better
Long-stay residents whose ability to walk worsened5.0%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication35.5%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine86.8%94.5%95.3%typical
Long-stay residents with pressure ulcers6.1%3.4%4.7%worse
Long-stay residents with worsening bladder/bowel control18.6%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table3.8%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication2.2%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine33.3%75.6%79.4%worse
Short-stay residents rehospitalized after admission27.3%24.9%22.6%worse
Short-stay residents with an outpatient ER visit16.8%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.611.731.67typical
Long-stay outpatient ER visits per 1,000 resident days1.131.801.80better

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.

12.3%U.S. median 10.7%
Went back to hospital
21.4%U.S. median 56.6%
Met the expected recovery
0.38U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 21.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 42 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% 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 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 SNF12.3%CMS range 8.1–18.010.7%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 discharge21.4%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 discharge23.8%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 discharge19.1%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 identified98.5%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 setting76.2%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 stay0.0%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 worsened2.9%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 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 SNFs1.261.02Oct 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

0.67
RN hours/ resident / day
1.47
LPN hours/ resident / day
2.36
Aide hours/ resident / day
4.51
Total nurse hours/ resident / day
0.51
RN hoursweekends
54.4%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 70 beds and averages 64.4 residents a day — about 92% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 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 4.03 hrs/resident/day on weekends vs 4.70 on weekdays — 14% thinner on weekends. RN hours go from 0.74 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as 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

8
deficiencies at the latest standard inspection (2025-01-23)
5
at the previous standard inspection (2022-05-20)

Deficiencies are more than at the previous inspection — worsening. 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 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Fcited before2025-01-23 · 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 policy review, the facility failed to ensure food was stored and served in accordance with professional standards for food safety. This deficient practice had the potential to affect all 65 residents who received food from the kitchen. The facility census was 65. Findings included: Observations, during initial tour of the kitchen, on 01/20/25 from 8:50 A.M. to 9:10 A.M., with the facility's Dietary Manager (DM) revealed the following: one 5-pound bag of frozen tater tots that was not in the original packaging and not labeled or dated with a use-by date in the walk-in freezer; one 16-ounce bag of broccoli that was not in the original package and was not labeled or dated with a use-by date in the walk-in freezer; one 5-pound container of peanut butter that was opened but not labeled with a date that was opened on the counter; and four 18-ounce containers of spices (one paprika, one garlic powder, one Italian seasoning, and one seasoned salt) that were opened but not labeled with a use-by date or the date they were opened that were noted 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-23 · 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 record review, staff interview and policy review, the facility failed to inform and provide written information regarding the resident's right to formulate an advance directive. This affected three (#16, #51, and #63) of three residents reviewed for advanced directives. The facility census was 65. Findings included: 1. Review of the admission record revealed Resident #51 was admitted on [DATE]. Resident #51 had a medical history that included diagnoses of chronic respiratory failure, atrial fibrillation, tracheostomy status, malignant neoplasm of the prostate, and type 2 diabetes mellitus. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was dependent on staff for all activities of daily living (ADLs). Review of Resident #51's care plan included a focus area revised on [DATE],…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-23 · 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, staff interview, provider interview, email communication reviews and policy reviews, the facility failed to implement the policy to ensure a nurse practitioner (NP) immediately reported an allegation of abuse to facility management when made aware of the allegation, resulting in late reporting to the state agency by the facility. This affected one (#59) of three residents reviewed for abuse. The facility census was 65. Findings included: Review of the admission record revealed Resident #59 was admitted on [DATE]. Resident #59 had a medical history including diagnoses of chronic respiratory failure with hypoxia, epilepsy, tracheostomy status, gastrostomy status, dependence on respiratory (ventilator) status, and dependence on supplemental oxygen. Review of the quarterly Minimum Data Set assessment (MDS), with an Assessment Reference Date (ARD) of 12/04/24, revealed Resident #59 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive…

    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 · D2025-01-23 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interviews, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual review, and policy review, the facility failed to identify and complete a Significant Change in Status Assessment (SCSA) when a resident was discharged from Hospice care. This affected one (#48) of 20 sampled residents reviewed. The facility census was 65. Findings included: Review of the admission record revealed Resident #48 was on 03/20/23. Resident #48 had a medication history including diagnoses of unspecified sequelae of nontraumatic intracerebral hemorrhage, vascular dementia with other behavioral disturbance, hemiplegia (partial paralysis) affecting the left nondominant side, dysarthria (difficulty speaking) following cerebral infarction (stroke), acute respiratory failure with hypoxia, tracheostomy status, and gastrostomy status. Review of the quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/23/24, revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe…

    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 before2025-01-23 · 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 — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record reviews, and policy reviews, the facility failed to ensure comprehensive person-centered care plans were developed and implemented. This affected four (#6, #11, #60, and #63) of 20 sampled residents reviewed. The facility census was 65. Findings included: 1. Review of the admission record revealed Resident #6 was admitted on [DATE]. Resident #6 had a medical history including diagnosis of Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/10/24, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS indicated the resident required partial to moderate assistance with all activities of daily living (ADLs). Review of Resident #6's care plan revealed no evidence of a focus, goal, or interventions related to the administration of oxygen therapy. Review of Resident #6's Order Summary Report, with active orders as 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-23 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and policy review, the facility failed to ensure resident's who were at nutritional risk had weights completed per policy. This affected two (#60 and #63) of three residents reviewed for nutrition. The facility census was 65. Findings included: 1. Review of the admission record revealed Resident #60 was admitted on [DATE]. Resident #60 had a medical history including diagnoses of a nontraumatic subarachnoid hemorrhage (brain bleed), dysphagia (difficulty swallowing), and gastrostomy status. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/07/24, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for all activities of daily living (ADLs). The MDS revealed and a (-) dash was placed where the resident's height and weight were to be recorded, as there was no admission height or weight…

    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 before2025-01-23 · 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 observation, staff interview, record review, and policy review, the facility failed to ensure staff obtained physician's orders for the use of supplemental oxygen. This affected one (#6) of two residents reviewed for oxygen therapy. The facility census was 65. Findings included: Review of the admission record revealed Resident #6 was admitted on [DATE]. Resident #6 had a medical history including diagnosis of Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/10/24, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS indicated the resident required partial to moderate assistance with all activities of daily living (ADLs). Review of Resident #6's care plan revealed no evidence of a focus, goal, or interventions related to the administration of oxygen therapy. Review of Resident #6's Order Summary Report, with active orders as of 01/20/25, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-23 · 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, staff interview, and record review, the facility failed to maintain appropriate infection control practices while providing tracheostomy care. This affected one (#51) of one resident observed for tracheostomy care. The facility census was 65. Findings included: Review of the admission record revealed Resident #51 was admitted on [DATE]. Resident #51 had a medical history including diagnoses of chronic respiratory failure and tracheostomy status. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/20/24, revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was dependent on staff for all activities of daily living (ADLs) and received tracheostomy care while at the facility and within the last 14 days of the assessment period of the MDS. Review of Resident #51's care plan included a focus area initiated on 10/26/24, that 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-11-21 · tag F0880 — failed to prevent and control infections — widespread
    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, staff interviews and record review, the facility failed to ensure a handwashing sink with flowing water had a filter in place to prevent the spread of Legionella. This affected all 34 residents (#34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54. #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66 and #67) on the third floor but had the potential to affect all 62 residents who resided in the facility. The facility also failed to ensure there were handwashing stations in resident rooms who were in Enhanced Barrier Precautions (EBPs). This affected 24 residents (01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, #12, #13, #14, #16, #19, #22, #23, #27, #29, #32, #33, #48, and #66) of the 24 residents who the facility identified as being in EBPs, but had the potential to affect all 62 residents who resided in the facility. The facility also failed to ensure outside a Laboratory Phlebotomist wore the appropriate personal protective…

    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 · F2024-11-21 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    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 observation, staff interviews and record review, the facility failed to ensure water temperatures were maintained within an appropriate range. This affected all 62 residents who resided in the facility. Findings include: Observation of the facility on 11/18/24 at 8:48 A.M., revealed the water temperature of the only operational handwashing sink located in the third floor shower room was 84 degrees Fahrenheit. The water temperature of the only operational handwashing sink located in the second floor shower room was 91.6 degrees Fahrenheit. Interview with Maintenance Assistant #79 on 11/18/24 at 8:48 A.M. verified the water temperature of the handwashing sink in the third floor shower room was 84 degrees Fahrenheit and the water temperature of the handwashing sink in the second floor shower room was 91.6 degrees Fahrenheit. Review of the facility's safety of water temperatures policy dated December 2009 revealed water heaters that service resident rooms, bathrooms, common areas and shower areas shall be set to temperatures between 105 and 120 degrees Fahrenheit.

    Environmental Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Ecited before2024-11-21 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and record review, the facility failed to ensure dependent residents were provided assistance with eating in a timely manner. This affected five (#35, #42 #47, #48, and #67) of the nine residents identified by the facility who required assistance with eating. The facility census was 62. Findings include: Review of Resident #42's medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included cachexia, mass and lump in the neck, chronic obstructive pulmonary disease, heart failure, insomnia, male erectile dysfunction, hypertensive heart disease with heart and diverticulosis of large intestine without perforation or abscess without bleeding. Review of Resident #42 admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was severely cognitively impaired and dependent on staff for eating. Observation of the third floor on 11/18/24 at 11:59 A.M. revealed the meal trays arrived on the floor. Certified Nursing Assistant (CNA)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-21 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and record review, the facility failed to maintain adequate staff levels to ensure the residents who required feeding assistance were timely provided with meals. This affected five (#35, #42 #47, #48, and #67) of the nine residents identified by the facility who required assistance with eating. The facility census was 62. Findings include: Review of Resident #42's medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included cachexia, mass and lump in the neck, chronic obstructive pulmonary disease, heart failure, insomnia, male erectile dysfunction, hypertensive heart disease with heart and diverticulosis of large intestine without perforation or abscess without bleeding. Review of Resident #42 admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was severely cognitively impaired and dependent on staff for eating. Observation of the third floor on 11/18/24 at 11:59 A.M. revealed the meal trays arrived 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-24 · 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 — 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 have a comprehensive care plan in place for residents receiving tracheostomy care. This affected one (Resident #15) of three residents reviewed for care plans. The in-house facility census was 65. Findings include: Record review for Resident #15 revealed Resident #15 was admitted on [DATE] with diagnoses including hemiplegia/hemiparesis, tracheostomy, and acute and chronic respiratory failure. Resident #15 required total dependence with activities of daily living. Review of the care plan dated 08/24/23 revealed Resident #15 has a tracheostomy related to impaired breathing mechanics. Intervention dated 08/24/23 was to suction as necessary. There was no care plan for tracheostomy care prior to 08/24/23 and there were no other interventions for tracheostomy care. Interview on 08/24/23 at 3:40 P.M. with Regional Clinical Director #40 verified there was no care plan for tracheostomy care indicating Resident #15 needed to have excessive…

    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 before2023-08-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, review of the facility investigation, and review of the facility policy, the facility failed to ensure residents who were dependent on staff for bathing received adequate bathing to promote proper hygiene. This affected one (Resident #15) of three residents reviewed for activities of daily living (ADLs.) The facility census was 68. Findings include: Review of the medical record for Resident #15 revealed the resident was admitted on [DATE]. Diagnoses included hemiplegia/hemiparesis, tracheostomy, gastrostomy, encephalopathy, and acute and chronic respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 required total dependence with all ADLs. Review of the care plan dated 02/23/23 revealed Resident #15 had an ADL self-care performance deficit related to disease process. Resident #15 required staff assist to complete ADL tasks daily. Fluctuations were expected related to diagnosis. At risk for decline in…

    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 · E2022-05-20 · 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

    Based on observation, staff interview, and review of facility policy, the facility failed to ensure medication carts were locked while unattended, dispose of expired medications, and store-controlled medications in a separately locked, permanently affixed compartment in refrigerator. This had the potential to affect four residents (#17, #20, #26, and #55) of four residents reviewed for medication storage. The facility census was 62. Findings include: 1. Observation on 05/16/22 at 9:57 A.M. revealed the medication cart on the second floor was unlocked and unattended. Interview on 05/16/22 at 10:00 A.M. with Licensed Practical Nurse (LPN) #225 verified that the medication cart was unlocked with no staff present. Observation on 05/16/22 at 11:56 A.M. revealed a second medication cart was unlocked and left unattended. Interview on 05/16/22 at 11:58 A.M. with LPN #225 verified that the medication cart was unlocked and left unattended. 2. Observation on 05/17/22 at 10:36 A.M. of the third-floor medication cart, revealed the following: a lantus insulin pen expired 05/03/22, belonging to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-05-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and service contract interviews, review of facility polices, review of sanitation logs, the facility failed to ensure food was stored, prepared, distributed and served food in accordance with professional standards for food service safety. This had the potential to effect 55 of 62 residents of the facility, excluding Residents #56, #414, #19, #22, #04, #01 and #09) who facility identified as receiving enteral feedings and nothing by mouth (NPO). Facility census was 62. Findings included: 1. During initial observation of the kitchen on 05/16/22 beginning at 9:15 A.M. with Dietary Manager (DM) #500 revealed the following: • Observation of the walk-in refrigerator #2 revealed puddling water throughout the refrigerator, which was running out of the refrigerator and into the adjacent room's drain. Further observation of refrigerator #2 revealed large areas of blackish, fuzzy substance, consistent with the appearance of mold, built-up on the walls and floors, which was approximately six…

    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 · Dcited before2022-05-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, observation, staff interview, and review of facility policy, the facility failed to ensure a resident was assisted with nail care. This affected one resident (#35) out of five residents reviewed for assistance with Activities of Daily Living (ADL). The facility census was 62. Findings include: Review of the medical record revealed Resident #35 admitted to the facility on [DATE] with diagnoses including, chronic obstructive pulmonary disease (COPD), unspecified schizophrenia, hypertension, and rheumatoid arthritis. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had moderately impaired cognition, had no behaviors and did not reject care. Resident #35 was a one-person assist and required limited assistance with bed mobility, toileting, and personal hygiene, and supervision for transfers, locomotion, dressing, and eating. Review of the care plan dated 04/06/2022 revealed Resident #35 had an ADL self-care deficit…

    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 before2022-05-20 · 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 medical record review, observations, staff interview, and review of facility policy, the facility failed to ensure a residents oxygen humidifier bottle contained water and was dated. This affected one resident (#35) of 16 residents identified as being on oxygen. The facility census was 62. Findings included: Review of the medical record for Resident #25 revealed an admission date of 12/30/17. Diagnosis included chronic obstructive pulmonary disease (COPD), muscle weakness, dysphagia, dementia, hemiplegia, and respiratory failure. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and required extensive assistance with activities of daily livings (ADLs). Further review revealed the resident received oxygen. Review of Resident #25's physician orders revealed an order dated 04/07/19 for oxygen via nasal cannula at two liters per minute (LPN). Further review of orders revealed an order dated 12/17/19…

    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 · D2022-05-20 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 review of facility policy, the facility failed to ensure residents were offered influenza vaccinations. Additionally, the facility failed to ensure pneumonia vaccinations were administered after obtaining representative consent. This affected two residents (#5 and #19) of five residents reviewed for immunizations. The facility census was 62. Findings include: 1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including hemiplegia, aphasia, dysphagia, hypothyroidism, and COVID-19. Review of document titled, Pneumococcal Polysaccharide Vaccine (PPSV23) Informed Consent, dated 01/21/2022, revealed Resident #5's representative signed consent for Resident #5 to receive a pneumonia vaccination at the facility. Consent for flu vaccination was blank and unsigned. Review of Medication Administration Records (MAR's) dated January 2022, February 2022, and March 2022 revealed Resident #5 had no physician order and…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-03-28 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on personnel file review and staff interview, the facility failed to ensure a state tested nursing assistant (STNA) received 12 hours of annual in-services and an annual performance evaluation. This affected one STNA (#30) of the four STNA's reviewed. This had the potential to affect all 62 residents residing in the facility. Facility census was 62. Findings include: Review of STNA #30's personnel file revealed the staff members date of hire was 10/05/16. Further review of STNA #30's personal filed revealed there was evidence of STNA #30 completing 12 hours of in-services annually. Additionally, STNA #30 also did not have an annual performance evaluation in file. Interview with Human Resources Coordinator on 03/28/19 at 2:36 P.M. verified STNA #30 did not have 12 hours of in-services and/or an annual performance evaluation. The facility confirmed this had the potential to affect all residents residing in the facility.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-03-28 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) letter to resident when discharged from Medicare Part A Services. This affected two Residents (#19, & #21) out of three Residents reviewed for SNF Beneficiary Protection Notification Review. The facility census was 62. Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include anemia, depression, hypertension, obstructive uropathy, history of urinary tract infections, diabetes mellitus and hyperlipidemia. Further review of SNF Beneficiary Protection Notification Review revealed the resident began Medicare Part A services on 12/18/19, the residents last cover day (LCD) was 01/11/19, the resident remained in the facility following the LCD and Resident #19 was not provided a SNF ABN letter when discharged from Medicare Part A services and transferred to nursing. 2. Review of Resident #21's…

    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 · D2019-03-28 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff interviews, review of personnel files, policy review and review of a job description, the facility failed to ensure licensed practical nurses (LPN) were intravenously (IV) certified when providing medications through a peripherally inserted central catheter (PICC). This affected one (#34) out of two residents who receive medications administered via a PICC line. The facility identified two residents who receive medications administered via PICC line. Facility census was 62. Findings include: Review of the medical record for the Resident #34, revealed an admission date of 01/03/19. Diagnoses included but not limited to osteomyelitis, atrial fibrillation, heart failure, major depressive disorder, diabetes, gangrene and gastro esophageal reflux disease (GERD). Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/28/19, revealed the resident was cognitively intact and the Brief Inventory of Mental Status (BIMS) score was 15. Resident required supervision only for all ADLs. Review of physician's orders for Resident #34 dated 03/05/19,…

    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 · D2019-03-28 · 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 medical record review, and staff interview, the facility failed to ensure residents medication regimen was free from unnecessary medications regarding as needed orders for psychotropic medication that were not limited to 14 days. This affected three residents (#49, #36 and #27) out of five Residents reviewed for unnecessary medications. The facility census was 62. Findings include: 1. Review of Resident #49's medical record revealed the resident was admitted on [DATE] with diagnosis including heart failure, atrial fibrillation, pneumonia, acute kidney failure, hypertension, diabetes, hyperlipidemia, glaucoma, anemia, dysphagia, muscle weakness, insomnia, dementia, depression, aphasia, hypothyroidism, urinary tract infection, cerebral infarction, and ataxia. Review of Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #49 has severely impaired cognitive skills, requires total dependence with all activities of daily living, and always incontinent of bowel and bladder.…

    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 · D2019-03-28 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and policy review, the facility failed to ensure residents were free from medication errors. This affected one (#49) resident out of three residents observed for medication administration or seven errors out of 31 opportunities or a 22.58 percent (%) medication error rate. The facility census was 62. Findings include: Review of Resident #49's medical record revealed the resident was admitted on [DATE] with diagnosis including heart failure, atrial fibrillation, pneumonia, acute kidney failure, hypertension, diabetes, hyperlipidemia, glaucoma, anemia, dysphagia, muscle weakness, insomnia, dementia, depression, aphasia, hypothyroidism, urinary tract infection, cerebral infarction, and ataxia. Review of Discharge Return Anticipated Minimum Data Set, dated [DATE] revealed Resident #49 has severely impaired cognitive skills, requires total dependence with all activities of daily living, and always incontinent of bowel and bladder. An observation on 03/26/19…

    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 before2019-03-28 · 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 medical record review, observation, staff and resident interview, and policy review, the facility failed to use appropriate infection control techniques and procedures while performing fasting blood sugars, and regarding the placement of indwelling urinary (foley) catheters collection bags. This affected one (#34) out of three residents observed during medication pass and one (#19) out of two residents reviewed for urinary catheters. This had the potential to affect four Residents (#6, #21, #34, & #114) identified by facility as needing fasting blood sugars and the facility identified two Residents (#6, & #19) with catheters on the unit. The facility census was 62. Findings include: 1. An observation on 03/27/19 at 8:27 A.M. revealed Licensed Practical Nurse (LPN) #140 performed a fasting blood sugar on Resident #34. After LPN #140 performed the blood sugar check on Resident #34 she placed glucometer on the medication cart. At 8:50 A.M. LPN #140 placed the glucometer in the medication cart without…

    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

No federal fines in the current CMS record.

Part of a chain

This home belongs to CCH HEALTHCARE — 33 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 52.5+0.5 vs chain
Health inspection 3 of 52.4+0.6 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 3 of 53.9-0.9 vs chain
The other 32 homes this chain runs (chain average 2.5★, per CMS)
1 of 5Carver Living CenterDurham, NC 1 of 5Countryside Manor Nursing And Rehabilitation LLCFremont, OH 1 of 5Harrison Pavilion Care CenterCincinnati, OH 1 of 5Meadowbrook Care CenterCincinnati, OH 1 of 5Smoky Mountain Health And Rehabilitation CenterPigeon Forge, TN 1 of 5The Greens at GastoniaGastonia, NC 1 of 5Valley Nursing and Rehabilitation CenterTaylorsville, NC 1 of 5Weakley Rehabilitation And Nursing CenterDresden, TN 2 of 5Cedars Of Lebanon Care CenterLebanon, OH 2 of 5Clovernook Health Care And Rehabilitation CenterCincinnati, OH 2 of 5Louisville Gardens Care CenterLouisville, OH 2 of 5Ridgewood Living & Rehabilitation CenterWashington, NC 2 of 5Solon Pointe At Emerald RidgeSolon, OH 2 of 5The Greens at HickoryHickory, NC 2 of 5The Greens at LincolntonLincolnton, NC 2 of 5The Greens at ViewmontHickory, NC 2 of 5Willow Ridge Of NCRutherfordton, NC 3 of 5Flint Ridge Nrsg & Rehab CtrNewark, OH 3 of 5Lincoln Crawford Care CenterCincinnati, OH 3 of 5Meadow Wind Health Care CenterMassillon, OH 3 of 5Northcrest Rehab And Nursing CenterNapoleon, OH 3 of 5Pineville Rehabilitation and Living CenterPineville, NC 3 of 5The Greens at HendersonvilleHendersonville, NC 3 of 5The Greens at Pinehurst Rehabilitation & Living CePinehurst, NC 3 of 5The Greens at Spruce PinesSpruce Pine, NC 4 of 5Cedarview Care CenterLebanon, OH 4 of 5Sunrise Nursing Healthcare LLCAmelia, OH 4 of 5The Greens at Maple LeafStatesville, NC 4 of 5The Greens at WeavervilleWeaverville, NC 4 of 5Twilight Gardens Nursing And RehabilitationNorwalk, OH 5 of 5Locust Ridge Healthcare LLCWilliamsburg, OH 5 of 5The Greens at CabarrusConcord, NC

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
SCARLET OAKS HEALTHCARE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/01/2016
SCARLET REALTY LLCOrganization5% OR GREATER SECURITY INTERESTsince 02/01/2016
MOORE, CYNTHIAIndividualW-2 MANAGING EMPLOYEEsince 02/01/2016
OLIVERIO, SUSANIndividualW-2 MANAGING EMPLOYEEsince 02/01/2016
STERN, JACOBIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/01/2016

2 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.

$10.9M
Net patient revenuemost recent cost report
-26.1%
Operating marginrevenue minus expenses
$543K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 14%Other / private 12%

About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $543K 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

$599per resident / day
operating cost
$18,202per month
≈ monthly operating cost
$475per 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 365978. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-23, 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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