Seven Acres Senior Living At Clifton
476 Riddle Road, Cincinnati, OH 45220 · For profit - Limited Liability company · 58 certified beds · (513) 281-8001 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0606), cited Apr 2021
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.1% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 5.2% | 6.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.0% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 17.9% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.1% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.9% | 6.1% | 16.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 15.1% | 25.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.1% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.8% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 1.4% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.8% | 8.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.32 | 1.73 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.87 | 1.80 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 29% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not 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 SNF | 11.2%CMS range 7.0–18.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not 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 discharge | not 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 discharge | not 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | 1.00 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 58 beds and averages 50.2 residents a day — about 87% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.554 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.13 hrs/resident/day on weekends vs 4.00 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.58 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% 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
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · Gcited before2023-08-23 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, resident interview, staff interview, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure Resident #46's pain was managed during a dressing change to the residents Stage IV pressure ulcer (full-thickens loss of skin and tissue loss with exposed or directly palpable fascia, muscle tendon ligament, cartilage, or bone in the ulcer) on her sacrum. This resulted in Actual Harm to Resident #46 when the resident was not pre-medicated for pain prior to the wound care treatment which resulted in the resident exhibiting signs of severe pain and the nurse continued the wound treatment without addressing the resident's pain. This affected one resident (#46) of the three residents reviewed for pain management. The facility census was 50. Findings include: Review of the record for Resident #46 revealed an admission date of 10/08/21 with diagnoses of multiple sclerosis (MS), diabetes mellitus (DM), dementia without behavioral disturbance, mood disorder, chronic viral hepatitis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, interview, and facility policy review, the facility failed to report an injury of unknown origin to the Ohio Department of Health (ODH). This affected one resident (#1) of five residents reviewed. The facility census was 56 at the time of survey.Findings Include:Review of the closed medical record revealed Resident #1, was admitted to the facility on [DATE] and discharged on 09/13/2025. Diagnoses included Discitis (thoracic region), Osteomyelitis of vertebra, Hypertensive Heart Disease with Heart Failure, Type II Diabetes Mellitus, and Chronic Diastolic Heart Failure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a BIMS of 12 out of 15 indicating mild cognitive deficits, he had no behaviors, did not reject care, and did not wander. Resident #1 was incontinent of bowel and bladder. Resident #1 was a two-person physical assist, was dependent for bed mobility, transfers, dressing, toileting, and personal hygiene, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-26 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, and policy review, the facility failed to ensure resident pneumococcal vaccinations were up to date. This affected five (#15, #17, #18, #19, and #37) of five residents reviewed for pneumococcal vaccinations. The facility census was 51. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 11/21/17. Diagnoses included acute kidney failure, major depressive disorder, acute respiratory failure with hypoxia, and metabolic encephalopathy. Review of the medical record for Resident #15 revealed Pneumococcal vaccine Prevnar 13 was given on 07/21/15. Resident #15 should have received Prevnar 20 (PCV20) or Pneumovax 23 (PPSV23) one year after PCV13; however, there was no documentation either was given. 2. Review of the medical record for Resident #17 revealed an admission date of 08/21/17. Diagnoses included type two diabetes mellitus, chronic kidney disease stage three, and chronic obstructive pulmonary disease (COPD). Review of the medical record for Resident #17 revealed the resident refused a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-26 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and staff interview, the facility failed to complete a baseline care plan within 48 hours after admission. This affected one (#14) of 15 residents reviewed for baseline care plans. The facility census was 51. Findings include: Review of the medical record for Resident #14 revealed an admission date of 05/30/24. Diagnoses included acute respiratory failure with hypoxia, pneumonia, dementia, and malignant neoplasm of prostate. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of seven. The resident was assessed to require supervision with eating and transfers, and required partial assistance with toileting, bathing, and dressing. Review of the baseline care plan dated 05/30/24 revealed it was not completed for Resident #14. Interview on 06/24/24 at 9:55 A.M. with MDS Nurse #22 verified Resident #14's baseline care plan had not 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.
- Potential for harm · D2024-06-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff and resident interview, the facility failed to ensure residents were provided with timely and adequate personal hygiene. This affected three (#6, #14, and #23) of four residents reviewed for activities of daily living (ADLs). The facility census was 51. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 03/27/24. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD) stage four, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. The resident was assessed to require supervision with eating, substantial assistance with toileting, bathing, and dressing, and partial assistance with transfers. Review of the care plan dated 03/28/24 revealed Resident #6 had an ADLs self-care performance deficit related to impaired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of a facility policy, the facility failed to appropriately assess pressure ulcers as required. This affected one (#51) of one resident reviewed for pressure ulcers. The facility census was 51. Findings include: Review of the medical record for Resident #51 revealed an admission of 04/01/24. Diagnoses included dementia, atrial fibrillation, type two diabetes mellitus, protein-calorie malnutrition, and malignant neoplasm of prostate. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of six. The resident was assessed to require supervision with eating, and was dependent with toileting, bathing, dressing, and transfers. Review of the care plan dated 05/15/24 revealed Resident #51 had a stage four pressure ulcer (full thickness skin and tissue loss) of the coccyx/sacrum related to impaired mobility, refusal 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.
- Potential for harm · Dcited before2024-06-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure resident fall risks were assessed after falls to determine risk factors to the resident. This affected two (#23 and #27) of four residents reviewed for falls. The facility census was 51. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 03/26/24. Diagnoses included type two diabetes mellitus, chronic kidney disease, depression, and atrial fibrillation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had severe cognitive impairment. The resident was assessed to require supervision with eating, and substantial assistance with toileting, bathing, and dressing, and dependent with transfers. Review of the care plan dated 03/26/24 revealed Resident #23 was at risk for falls related to deconditioning and gait/balance problems. Interventions included Dycem (non-slip device) to wheelchair to reduce risk for sliding out…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-26 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure nutritional assessments were completed and interventions were put into place timely for residents with significant weight loss and at risk for nutritional deficits. This affected two (#18 and #51) of four residents reviewed for nutrition. The facility census was 51. Findings include: 1. Review of Resident #18's medical record revealed the resident was readmitted to the facility on [DATE]. Diagnoses include malnutrition, heart failure, atrial fibrillation, congestive heart failure , peripheral neuropathy, anemia, thrombophilia, leukemia, and depression. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition and required supervision for meal assistance. The resident received a no added salt diet and a supplement three times a day. Review of physician orders revealed weekly weights were ordered by the physician on 11/17/23. Review of the plan of care revealed Resident #18…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to perform adequate hand hygiene and provide care in a manner to prevent potential contamination during wound and urinary catheter care. Additionally, the facility failed to ensure residents were placed on enhanced barrier precautions as required for residents with wounds and/or indwelling medical devices. This affected one (#51) resident of six residents reviewed for infection control measures. The facility census was 51. Findings include: Review of the medical record for Resident #51 revealed an admission date of 04/01/24. Diagnoses included dementia, atrial fibrillation, type two diabetes mellitus, protein-calorie malnutrition, and malignant neoplasm of prostate. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of six. The resident was assessed to require supervision 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.
- Potential for harm · Dcited before2024-05-08 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's pain was addressed. This affected one resident (#29) of one resident reviewed for pain. The facility census was 52. Findings include: Review of the medical record revealed Resident #29 admitted to the facility on [DATE] with diagnoses including hypertensive heart disease with heart failure, pulmonary hypertension, congestive heart failure, type two diabetes mellitus with diabetic neuropathy, hyperlipidemia, bipolar disorder, gastro esophageal reflux disease without esophagitis, post traumatic stress disorder, anemia, asthma, restless legs syndrome, obstructive sleep apnea, and major depressive disorder. Review of Resident #29's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #29 received opioid medication during the review period and rated her worst pain over the past five days as a four out of ten. Review of Resident #29's opioid medication care plan dated 04/08/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-08 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's insulin pen was primed according to manufacturer guidelines resulting in a significant medication error. This affected one (Resident #8) of five residents observed for medication administration. The facility census was 52. Findings include: Review of the medical record for Resident #8 revealed an admission date of 11/09/19. Medical diagnoses included but were not limited to diabetes mellitus, [NAME] syndrome, dementia and heart failure. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. Resident #8 required moderate assistance for toileting, transfers, and bed mobility. Review of the active physicians orders for Resident #8 revealed an order dated 03/20/24 for NovoLOG Injection Solution 100 unit/milliliters (ml) (Insulin Aspart), inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units;…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · Dcited before2024-05-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interviews, the facility failed to ensure nurses handled resident medications in a sanitary manner. This affected two (Residents #3 #22) of five residents observed for medication administration. Facility census was 52. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 01/27/23 with diagnoses including but not limited to dementia without behavioral disturbances, hypertension, wernicke's encephalopathy, anemia, and alcoholic cirrhosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 revealed intact cognition. Resident #3 was dependent for toileting and transfers, and required moderate assistance for bed mobility and transfers. Review of the active physicians orders for Resident #3 revealed an order for cranberry oral tablet give two tablets by mouth three times a day. Observation on 05/08/24 at 11:20 A.M. of medication administration with Registered Nurse (RN) #225 to Resident #3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record, observation, staff interview, and review of the facility policy the facility failed to timely implement treatment orders for residents with skin breakdown. This affected one (Resident #17) of three residents reviewed for skin breakdown. The facility census was 46. Findings include: Review of the medical record for Resident #17 revealed an admission date of 06/15/23 with diagnoses including dementia, chronic obstructive pulmonary disease (COPD), and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 12/22/23 revealed the resident had moderate cognitive impairment, required supervision with eating and was dependent on staff for toileting, bathing, and transfers. Review of the care plan for Resident #17 dated 02/07/24 revealed the resident had an arterial/ischemic ulcer between the right great toe and second toe. Interventions included the following: assess for pain and administer medications as ordered, staff to inspect feet daily and report any changes to the nurse, staff to monitor and document wound including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-12 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, medical record review, staff interviews and spread sheet review, the facility failed to serve the correct amount of puree food texture portions as listed on the menu spreadsheet. This affected four (#21, #35, #39 and #47) of four residents observed who required an ordered puree texture diet. The facility total census was 48. Findings include: Review of Residents #21, #35, #39 and #47's monthly March 2024 physician orders revealed the residents had physician orders for puree texture diets. Review of the lunch menu spreadsheet dated 03/07/24 revealed the puree texture diet should have received three ounces puree meat, four ounces of vegetable, and four ounces of starch. Review of the meal tickets of Residents #21, #35, #39 and #47 revealed no notation the residents preferred small food portions. Observation on 03/07/24 at 12:15 P.M., revealed Residents #21, #35, #39 and #47 were served by Diet Aides, (DA) #45 and #50, puree meat of two ounces, three ounces of vegetable and three ounces of starch. The serving utensils were not completely filled to an accurate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interview, and review of the facility policy, the facility failed to ensure medications were stored safely and not left unattended. This affected Resident #3 and had the potential to affect nine additional facility-identified residents (#2, #5, #8, #9, #17, #19, #20, #22, and #23) residing on the second floor who were cognitively impaired and independently mobile. The facility census was 49 residents. Findings include: Review of the medical record for Resident #3 revealed an admission date of 03/01/23 with diagnoses including dementia without behavioral disturbance, chronic kidney disease (CKD), peripheral vascular disease (PVD), osteoarthritis (OA), and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively impaired and required limited assistance of one staff with activities of daily living (ADLs.) Review of the monthly physician orders for Resident #3 revealed orders dated 10/28/22 for multivitamin one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-13 · tag F0880 — failed to prevent and control infections — patternProvide 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 record review, observation, staff interview, and review of manufacturer's guidelines for glucometer use, the facility failed to ensure staff properly cleaned and disinfected glucometers after use. This affected Resident #45 and had the potential to affect 20 residents (#25, #26, #27, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #42, #44, #47, #48, and #49) who the facility identified to receive blood glucose monitoring utilizing the same glucometer as Resident #45. Findings include: Review of the medical record for Resident #45 revealed an admission date of 05/24/23 with a diagnosis of diabetes mellitus (DM.) Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively intact. Review of the physician orders dated 07/17/23 revealed an order for Resident #45 to receive insulin per sliding scale at meals based upon results of blood sugar check. Observation on 09/12/23 at 11:33 A.M. revealed Licensed Practical Nurse (LPN) #775 checked Resident #45's blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of the facility policy and review of online resource, guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to properly assess residents for risk factors for developing pressure ulcers, failed to conduct an admission skin assessment, and failed to implement a care plan to prevent the development of pressure ulcers. This affected one resident (#08) of three residents reviewed for pressure ulcers. The facility identified three residents with pressure ulcers. The census was 50 residents. Findings include: Review of the medical record for Resident #08 revealed an admission date of 08/04/23 with diagnoses including malignant neoplasm of the colon, hypertension, and sciatica, and a discharge date of 08/22/23. Review of the admission assessment and baseline care plan for Resident #08 dated 08/04/23, revealed the assessment was incomplete and it did not include an assessment of the resident's skin, resident's risk factors for the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident interview, staff interview, review of facility incident log, and review of the facility policy, the facility failed to investigate resident falls and implement interventions to prevent recurrence. This affected one resident (#38) of three residents reviewed for falls. The facility census was 50 residents. Findings include: Review of the medical record for Resident #38 revealed an admission date of 08/17/23 with diagnoses including hypertension, chronic kidney disease, and major depressive disorder. Review of the care plan dated 08/18/23 for Resident #38, revealed the resident was at risk for falls related to gait/balance problems. Interventions included the following: ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, monitor for attempts to self-rise and periods of restlessness, non-skid socks to bed worn in bed, therapy evaluate and treat as ordered or as needed, be sure the resident's call light is within reach…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2021-04-29 · tag F0606 — failed to not employ staff found guilty of abuse — widespreadNot hire anyone with a finding of abuse, neglect, exploitation, or theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on personnel file review, interview and policy review, the facility failed to ensure staff were checked against the Nurse Aide Registry prior to employment. This had the potential to affect all 40 residents residing in the facility. Findings include: Review of personnel records revealed no evidence of employees being checked against the State Nurse Aide Registry prior to employment for the following: Dietary Aide (DA) #92 hired on 08/13/19; DA #36 hired on 03/07/19; DA #94 hired on 10/13/20; DA #56 hired on 07/15/20; DA #51 hired on 08/19/20, DA #30 hired on 12/17/20; and DA #109 hired on 02/04/21. Receptionist #125 hired on 05/20/19; Receptionist #101 hired on 04/22/21; and Receptionist #100 hired on 02/18/21, Porter #70 hired on 05/13/20. Dishwasher #99 hired on 10/21/20. Activities Assistant #120 hired on 10/21/20. Scheduler #43 hired on 11/03/20. Business Office Manager (BOM) #23 hired on 09/28/20. Dietary Manager (DM) #89 hired on 04/06/21. Maintenance Specialist (MS) #119 hired on 03/31/21. Interview with the Human Resource Director (HRD) #3 on 04/28/21 at 7:28 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.
- Potential for harm · Dcited before2021-04-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview and policy review, the facility failed to address a slow weight loss, failed to provide the appropriate diet and failed to ensure supervision was provided during meals. This affected two (Residents #32 and #17) of six residents identified with significant weight loss. The facility census was 40. Findings include: Record review for Resident #32 revealed an admission date of 11/21/17. Medical diagnoses included muscle weakness, overactive bladder, and hypertension. Review of the care plans dated 12/31/19 revealed to provide companionship at mealtime to encourage nutritional intake Review of the weights for Resident #32 revealed on 10/13/20, the resident weighed 153 pounds; 11/09/20, 149 pounds; 12/05/20, 146 pounds; 01/12/21, 145 pounds; 02/04/21, 143 pounds; 03/05/21, 141 pounds; and 04/05/21, 138 pounds. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/09/21, revealed Resident #32 was severely cognitively impaired. She was able to feed herself. She was not on a prescribed weight loss program. Review of the dietician…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2019-04-11 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, staff interview and review of the facility's Legionella policy, the facility failed to follow their plan for monitoring water temperatures for the prevention of Legionella. This had the potential to affect all 52 residents residing in the facility. Findings include: Review of the facility's temperature logs revealed there were no water temperatures recorded for the sentinel taps. Interview on 04/11/19 at 3:17 P.M. with Facilities Operations Director #227 verified that the facility was not following the Legionella temperature monitoring schedule outlined in the facility's policy. He stated no temperatures have been taken nor recorded. He also verified the policy stated that hot and cold water temperatures would be checked monthly. Review of the facility's Legionella policy, dated 09/2017, revealed the facility will check monthly the hot water temperatures at the clarifier and the sentinel taps and the cold water temperatures at the sentinel taps.
- Potential for harm · D2019-04-11 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 policy review, review of facility self reported incidents (SRI) , medical record review, and staff interview, the facility to follow their abuse policy by not immediately reporting and thoroughly investigating allegations of abuse. This affected two (Resident #20 and #21) of four residents reviewed for abuse. The facility census was 52. Findings include: 1. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression, congestive heart failure, right femur fracture and rheumatoid arthritis. Review of the resident's Minimum Data Set assessment (MDS) assessment, dated 02/04/19, indicated the resident had moderate cognitive impairment for daily decision making. Review of the facility's self reported incident (SRI) control number 166484 indicated on 01/03/19 on two separate occasions, it was witnessed that the employee (State Tested Nursing Assistant #307) had a verbal confrontation with the resident. After many interviews with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-04-11 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, review of facility self reported incidents (SRI), medical record review, and staff interview, the facility failed to immediately report allegations of abuse. This affected two (Resident #20 and #21) of four residents reviewed for abuse. The facility census was 52. Findings include: 1. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression, congestive heart failure, right femur fracture and rheumatoid arthritis. Review of the resident's Minimum Data Set assessment (MDS) assessment, dated 02/04/19, indicated the resident had moderate cognitive impairment for daily decision making. Review of the facility's self reported incident (SRI) control number 166484 indicated on 01/03/19 on two separate occasions, it was witnessed that the employee (State Tested Nursing Assistant #307) had a verbal confrontation with the resident. After many interviews with the resident and other employee witnesses, it was determined that the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-11 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, policy review and review of facility's self-reported incidents (SRI), the facility failed to conduct a thorough abuse investigation. This affected one (Resident #21) of four residents reviewed for abuse. The facility census 52. Findings include: Record review for Resident #21 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, Parkinson's disease, anxiety disorder, major depressive disorder, and abnormalities of gait and mobility. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/04/19, revealed the resident had intact cognition and required physical assistance of one to two persons for activities of daily living. Review of the Self Reported Incident (SRI) control number 165704, dated 12/18/18, revealed Resident #21 reported to the assigned nurse (Registered Nurse #308) on 12/13/18 that State Tested Nursing Assistant (STNA) #306 had been rough, was in too much of a hurry, and was aggressive when assisting the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-11 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, review of facility policy, and review of the Clinical Resource information sheet, the facility failed to ensure expired medications were not available for resident use. This affected two of three medication carts reviewed for expired medications. The facility identified three residents receiving insulin and one resident receiving oyster shell calcium with vitamin D. The facility census was 52. Findings include: 1. Observation on 04/09/19 at 5:48 P.M. revealed the second floor medication cart contained an open vial of Novolog insulin labeled for Resident #24. The vial contained a hand-written date indicating that it was opened on 02/28/19, indicating the vial had been opened 40 days. Licensed Practical Nurse (LPN) #126 verified the finding at the time of the observation and stated the medication should have been discarded after having been open for 28 days. 2. Observation on 04/10/19 at 9:08 A.M. revealed the third floor medication cart contained an opened stock bottle of oyster shell calcium 500 milligrams (mg.) with vitamin D 200 international…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2021-04-29 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 and interview, the facility failed to notify the Ombudsman when a resident was transferred to the hospital. This affected two (Residents #2 and #37) of four residents reviewed for hospitalizations. The in-house facility census was 40. Findings include: 1. Record review revealed Resident #2 was transferred to the hospital on [DATE] with a change in condition. Review of a nursing note dated 02/28/2021 at 11:51 P.M. revealed 911 was notified and Resident #2 was transported to lobby area where paramedics were awaiting. Resident #2 was assessed by medic and transported to hospital without incident. Power of Attorney notified. Bed hold notice given and signed. There was no evidence the Ombudsman was notified of the resident's transfer to the hospital. 2. Record review revealed Resident #37 was transferred to the hospital on [DATE]. Review of a nursing note dated 04/22/21 at 10:04 P.M. revealed Resident #37 left facility at 6:45 P.M. via 911. Bed hold notice given. There was no evidence the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2023-09-15 for 12 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| KLINGERMAN, DAVID | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 10% | since 03/01/2023 |
| JERSEY SHORE STATE BANK | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 03/01/2023 |
| NIJAK, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2023 |
| SEROTA, GRETCHEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2023 |
| LIBERTY HEALTHCARE MGT LLC | Organization | ADP OF THE SNF | — | since 03/01/2023 |
CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
About 86% 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. 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 366316. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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