No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Brown Memorial Home INC

158 E Mound St, Circleville, OH 43113 · Non profit - Corporation · 44 certified beds · (740) 474-6238 Medicare & Medicaid certified

Call the home — (740) 474-6238 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 23 lower-level deficiencies on record (see below)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (60%) runs well above the national median (45%)

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
222 E Main St · (740) 474-3860 · Call to confirm hours
Pharmacy
Walmart0.1 mi
1470 S Court St · (740) 474-9898 · Call to confirm hours
Grocery
900 S Pickaway St · (740) 474-6501 · Call to confirm hours
Park
133 W Main St · 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 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

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

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.8%5.3%15.4%typical
Long-stay residents who lose too much weight1.1%6.2%5.4%better
Long-stay residents with a catheter left in their bladder1.5%0.2%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.8%0.4%2.0%typical
Long-stay residents with depressive symptoms35.0%30.1%6.5%worse 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 injury5.3%3.2%3.3%worse
Long-stay residents whose ability to walk worsened12.5%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication14.6%25.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers3.1%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control26.1%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.6%8.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication3.8%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine96.3%75.6%79.4%better
Short-stay residents rehospitalized after admission53.1%24.9%22.6%worse
Short-stay residents with an outpatient ER visit30.9%12.9%12.0%worse

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

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

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

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

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

60.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

60.7%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
0.28U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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 SNF60.7%CMS range 47.7–72.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 6.2–15.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 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

0.88
RN hours/ resident / day
1.25
LPN hours/ resident / day
2.06
Aide hours/ resident / day
4.18
Total nurse hours/ resident / day
0.62
RN hoursweekends
60.0%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 44 beds and averages 35.3 residents a day — about 80% occupied, or roughly 9 beds typically open. It usually has some room. 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 4.18 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 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 3.37 hrs/resident/day on weekends vs 4.52 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.99 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3
deficiencies at the latest standard inspection (2025-12-24)
12
at the previous standard inspection (2024-09-05)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Dcited before2025-12-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, staff interview, and facility policy review, the facility failed to adequately monitor skin issues/bruising for residents know to have skin alterations. This affected one (Resident #17) of three residents reviewed for skin alterations. The census was 33. Findings Include:Resident #17 was initially admitted to the facility for respite care on 07/07/25. Her diagnoses were Alzheimer's disease, dementia, amnesia, visual hallucinations, chronic fatigue, nonrheumatic mitral valve insufficiency, and encounter for palliative care. Review of her minimum data set (MDS) assessment, dated 11/18/25, revealed she had a severe cognitive impairment.Review of Resident #17 progress notes, dated 12/04/25, revealed hospice shower aid came to the facility nurse and stated she noted some bruising and swelling on Resident #17's lower left extremity (LLE). It was noted there were two dark colored bruises, but there was no measurement, description or exact location of the skin alteration. Review of Resident #17's progress notes, dated 12/05/25 to 12/19/25, revealed no…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-24 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 gradual dose reduction (GDR) pharmacy recommendations were completed as required. This affected one (Resident #20) of five residents reviewed for unnecessary medications. The census was 33.Resident #20 was admitted to the facility on [DATE]. Her diagnoses were gastro-esophageal reflux disease, emphysema, hyperlipidemia, morbid obesity, major depressive disorder, congestive heart failure, osteoarthritis, Type II Diabetes, chronic obstructive pulmonary disease, fibromyalgia, obstructive sleep apnea, hypertension, vitamin D deficiency, and history of falling. Review of her minimum data set (MDS) assessment, dated 09/14/25, revealed she was cognitively intact. Review of Resident #20's physician orders found the following medications ordered/administered and the dates in which they were initiated: Wellbutrin (antidepressant) 150 milligrams (mg) for depression, which was initiated on 03/11/24, and Citalopram (antidepressant) 10 mg, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-24 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to monitor the use of blood pressure medication appropriately. This affected two (Residents #11 and #5) of five residents reviewed for unnecessary medications. The census was 33.Findings Include: 1. Resident #11 was admitted to the facility on [DATE]. Her diagnoses were other long term drug therapy, anxiety disorder, Alzheimer's disease, dementia, repeated falls, hyperlipidemia, orthostatic hypotension, personal history of other diseases, visual hallucinations, cardiac murmur, restless leg syndrome, osteoporosis, neurocognitive disorder with Lewy bodies, and Parkinson's disease. Review of her minimum data set (MDS) assessment, dated 09/06/25, revealed she was cognitively intact. Review of Resident #11's current physician orders revealed an order for Midodrine HCl (used to treat low blood pressure) oral tablet 2.5 milligrams (mg), one tablet daily for hypotension. There were parameters documented to hold the medication if the systolic 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-05-28 · 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 — an excerpt from the official record, may be distressing

    Based on observation and staff interview, the facility failed to ensure shower room exhaust fans were maintained in good and working order. This had the potential to affect all 33 residents identified by the facility as using the shower rooms. The facility census was 33. Findings include: Observation and interview with the Director of Nursing (DON) on 05/28/25 at 11:00 A.M. confirmed the exhaust fans in the front and back shower rooms were not working. A small amount of a mildew-like substance was present on the ceiling around the exhaust fan in the back shower room. The DON stated she was not sure if parts had been ordered to repair or replace the exhaust fans but she would check. Interview with the DON on 05/28/25 at 12:33 P.M. confirmed there were no receipts or records of parts for the shower room exhaust fans being ordered. Interview with Maintenance Supervisor #299 on 05/28/25 at 1:20 P.M. confirmed the exhaust fans in the front and back shower rooms were not working and no parts had been ordered prior to 05/28/25 to repair or replace them. This deficiency represents…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-09-05 · 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 observations, staff interview, and facility policy review, the facility failed to appropriately date opened food items in the refrigerator and freezer. The deficient practice had the potential to affect all 39 residents who resided in the facility. The facility did not identify any residents with a physician ordered nothing by mouth (NPO) diet. Findings Include: Observations completed during the initial tour of the kitchen on 09/03/24 at 10:20 A.M. with Dietary Manager (DM) #106 revealed the following items in the refrigerator had been opened and not dated: One large glass container of dill pickle spears One large plastic container of mayonnaise, 75% empty One plastic container of pimento cheese spread One large plastic container with a handle of Pace Picante salsa One bottle of Frank's Red Hot sauce One bottle of Siracha hot sauce Two small plastic containers of chicken base One small container of beef base One small jar of minced garlic One small jar of sliced jalapenos One large plastic container of sour cream One large plastic container of ham salad One large plastic…

    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 · D2024-09-05 · 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

    Based on record review, review of the facility's beneficiary notice list and notices, staff interview, and facility policy review, the facility failed to provide an Advanced Beneficiary Notice (ABN) to one resident (Resident #141) when he was discharged from Medicare part A services and remained in the facility. The deficient practice affected one resident (Resident #141) of one reviewed for beneficiary notices. The facility census was 39. Findings Include: Review of the closed record for former Resident #141 revealed an original admission date on 01/08/24, readmission dates on 04/05/24 and 06/30/24, and a discharge date on 07/13/24. Medical diagnoses included complete traumatic amputation of right midfoot, protein-calorie malnutrition, dementia with behavioral disturbance, Type II Diabetes Mellitus with diabetic polyneuropathy, non-pressure chronic ulcers of right and left feet, peripheral vascular disease, and osteoarthritis. Review of the facility's Beneficiary Notice-Residents discharged Within the Last Six Months revealed Resident #141 was discharged from Medicare Part A…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-05 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    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 and record review the facility failed to document a resident transfer in the medical record when Resident #23 was transferred to the hospital for a change in condition. This affected one (Resident #23) of three Residents reviewed for hospitalization. The facility census was 39. Findings include: Record review of Resident #23 revealed an admission date of 12/27/19 with pertinent diagnoses of, fracture of unspecified part of neck of left femur, benign neoplasm of cerebral meninges, pick's disease, dementia with severe mood disturbance, anxiety disorder, seizures, atrial fibrillation, major depressive disorder, mood disorder with depressive features, anxiety disorder, and insomnia. Review of the 06/07/24 quarterly Minimum Data Set (MDS) assessment revealed the resident is rarely or never understood. The resident did not use mobility devices and wandered one to three days during the look back period. The resident was dependent for eating, oral hygiene, toileting, shower, upper body and lower…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-05 · tag F0623 — isolated
    Provide 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, staff interview, and facility policy review, the facility failed to notify the local Ombudsman when two residents (Residents #35 and #23) were transferred out of the facility and/or discharged from the facility. The deficient practice affected two residents (Residents #35 and #23) of four reviewed for hospitalizations and discharge. The facility census was 39. Findings Include: Review of the medical record for Resident #35 revealed and initial admission date on 08/08/23 and a readmission date on 04/23/24. Medical diagnoses included congestive heart failure, chronic obstructive pulmonary disease, and progressive systemic sclerosis. Review of the clinical census for Resident #35 revealed the resident was hospitalized on [DATE] and 06/24/24. Review of the discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had an unplanned discharge from the facility with return anticipated. Review of the discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-05 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of bed hold notices, and facility policy review, the facility failed to notify two residents (Residents #35 and #23) of the number of bed hold days each resident had remaining upon being transferred to the hospital from the facility. The deficient practice affected two residents (Residents #35 and #23) of three reviewed for hospitalizations. The facility census was 39. Findings Include: Review of the medical record for Resident #35 revealed and initial admission date on 08/08/23 and a readmission date on 04/23/24. Medical diagnoses included congestive heart failure, chronic obstructive pulmonary disease, and progressive systemic sclerosis. Review of the clinical census for Resident #35 revealed the resident was hospitalized on [DATE] and 06/24/24. Review of the discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had an unplanned discharge from the facility with return anticipated. Review of the discharge Minimum Data Set (MDS) 3.0…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-05 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 staff interview and record review the facility failed to update the Preadmission Screening Resident Review (PASRR) documents when a resident received a new mental health diagnosis. This affected two (Resident #10, and #34) of four residents reviewed for PASRR. The facility census was 39. Findings include: 1. Record review of Resident #10 revealed an admission date of 07/29/21 with pertinent diagnoses of, vascular dementia with mild agitation, obesity, gastroenteritis and colitis, low back pain, schizoaffective disorder, bipolar disorder, abdominal distension, hyponatremia, localized edema, major depressive disorder, seasonal allergic rhinitis, age related osteoporosis, paranoid schizophrenia, pneumocystosis, extrapyramidal and movement disorder, psychosis, hallucinations, anxiety disorder, delusional disorders, type two diabetes mellitus, cerebral amyloid angiopathy, gastro-esophageal reflux disease, hypertension, insomnia, and chronic obstructive pulmonary disease. Review of the 08/06/24 annual Minimum…

    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
Show the remaining 13 citations
  • Potential for harm · D2024-09-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to revise care plans when significant changes in the resident's condition occurred. This affected one (Resident #34) of 15 resident care plans reviewed. The census was 39. Findings Include: Resident #34 was admitted to the facility on [DATE]. Her diagnoses were cervicalgia, anxiety disorder, schizoaffective disorder, chronic obstructive pulmonary disorder, bipolar disorder, hyperlipidemia, drug induced subacute dyskinesia, hypertension, osteoarthritis, and personal history of irradiation. Review of her Minimum Data Set (MDS) assessment, dated 06/01/24, revealed she was cognitively intact. Review of Resident #34's current physician orders revealed she was not on hospice care at that time. Review of her previous/discontinued physician orders found she was discharged from hospice care on 02/23/24. Review of Resident #34's nutritional notes, dated 08/15/24, revealed a recommendation from the dietitian to decrease her chocolate/strawberry milk…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and resident record review, the facility failed to ensure the care planned assistance devices were properly placed to prevent falls for one (Resident #89) of three reviewed for accident hazards. The census was 39. Findings Include: Review of the medical record for Resident #89 on 09/03/24 at 9:58 A.M. revealed an admission date of 09/01/24 with a diagnosis of atherosclerotic heart disease of native coronary artery. Review of a skilled nurse's note dated 09/01/24 at 10:09 P.M. revealed Resident #89 had a history of falls with multiple falls within the last six months. Review of the baseline careplan dated 09/01/24 at 10:14 P.M. revealed documented fall interventions including: Non-skid footwear, parameter mattress, bed in low position, and mattress to floor. Review of a nurse's note dated 09/02/24 at 5:35 A.M. revealed that the nurse was alerted by an aide that Resident #89 was found laying on the floor by his bed on his back. Observations on 09/03/24 at 9:58 A.M. and 1:42 P.M., and again on 09/04/24 at 9:51 A.M. accompanied by the Director of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-05 · 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 record review, staff interview, and facility policy review, the facility failed to ensure Bilevel Positive Airway Pressure (BiPAP) (a machine that helps to push air into your lungs) settings were included in the physician order for one resident (Resident #35). The deficient practice affected one resident (Resident #35) of one reviewed for respiratory care. The facility census was 39. Findings Include: Review of the medical record for Resident #35 revealed and initial admission date on 08/08/23 and a readmission date on 04/23/24. Medical diagnoses included congestive heart failure, chronic obstructive pulmonary disease, secondary pulmonary arterial hypertension, and progressive systemic sclerosis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #35 required partial to moderate assistance with tub transfers and showering but was independent 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-05 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to obtain proper parameters for as needed pain medications. This affected two (Residents #34 and #29) of five residents reviewed for unnecessary medications. The census was 39. Findings Include: 1. Resident #34 was admitted to the facility on [DATE]. Her diagnoses were cervicalgia, anxiety disorder, schizoaffective disorder, chronic obstructive pulmonary disorder, bipolar disorder, hyperlipidemia, drug induced subacute dyskinesia, hypertension, osteoarthritis, and personal history of irradiation. Review of her Minimum Data Set (MDS) assessment, dated 06/01/24, revealed she was cognitively intact. Review of Resident #34's medical records revealed her physician orders included Oxycodone (opioid medication for pain) five milligrams (mg) every eight hours as needed for pain and Acetaminophen (analgesic medication to relieve pain) 650 mg every four hours as needed for pain. Review of his physician orders, Medication…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-05 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to administer blood pressure medication as ordered to one resident (Resident #29). The deficient practice affected one resident (Resident #29) of five reviewed for unnecessary medications. The facility census was 39. Findings Include: Review of the medical record for Resident #29 revealed an original admission date on 10/18/21 and a readmission date on 08/14/22. Medical diagnoses included essential primary hypertension, paroxysmal atrial fibrillation, morbid obesity, type II diabetes mellitus without complications, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #29 required varied amounts of assistance from staff to complete Activities of Daily Living (ADLs) which ranged from independence with eating to dependence on staff for showering,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-05 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interview, and facility policy review, the facility failed to ensure pureed food items were prepared at an appropriate texture prior to surveyor intervention for one resident (Resident #17). The deficient practice affected one resident (Resident #17) of one who had a physician ordered pureed diet. The facility census was 39. Findings Include: Observation on 09/04/24 at 10:50 A.M. of pureed food items with [NAME] #120 revealed the cook added one breaded pork chop and ¼ cup of hot water to a blender and started blending. Another ¼ cup of hot water was added to the blender. At 10:57 A.M., [NAME] #120 chopped another breaded pork chop on a cutting board and added it to the blender. Another ½ cup of hot water was added to the blender and continued blending. At 11:00 A.M., [NAME] #120 stopped the blender. [NAME] #120 scraped the sides of the blender and poured the pureed pork chops into a small Styrofoam container. This surveyor observed the pureed pork chops to be visibly stringy and watery. Interview on 09/04/24 at 11:02 A.M. with [NAME] #120 confirmed she…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2021-11-10 · 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 observations, staff interviews, review of the facility's policy, review of the Centers for Disease Control and Prevention (CDC) guidance, and record reviews, the facility failed to appropriately wear Personal Protective Equipment (PPE) during the COVID-19 pandemic, and failed to perform appropriate hand hygiene during wound care for Resident #12 and medication administration for Resident #11. This had the potential to affect all 37 residents who resided in the facility. Findings include: 1. Review of Resident #12's medical record revealed an original admission date of 08/24/21. Diagnoses included congestive heart failure, peripheral vascular disease, depression, chronic obstructive pulmonary disease, atherosclerotic heart disease, pneumonia, E. coli infection of gastrointestinal tract, chronic kidney disease, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/13/21, revealed Resident #12 had clear speech, always understood others, always made himself…

    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 · Dcited before2021-11-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident and staff interview, review of the facility's policy, and record review, the facility failed to provide appropriate monitoring and treatment of adverse side effects for residents receiving anticoagulation therapy. This affected two (#26 and #234) of three residents reviewed for medications. The facility identified 10 residents on anticoagulation therapy. The facility identified census was 37. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 09/30/21. Resident #26's diagnoses included chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 10/07/21, revealed Resident #26 was receiving an anticoagulant medication. The MDS assessment was silent for any skin conditions. Review of the physician orders for Resident #26, dated 10/01/21, revealed an order for Eliquis (anticoagulant) tablet 5.0 milligram (mg) by mouth twice daily. Review of the medical record for Resident #26 revealed skin assessments to be…

    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 · D2021-11-10 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 provide physician ordered interventions to prevent a resident's decrease in range of motion. This affected one (#4) of one resident reviewed for limited range of motion. The facility identified four residents with contractures. The facility census was 37. Findings include: Record review for Resident #4 revealed the resident was admitted to the facility on [DATE] with diagnoses including primary generalized arthritis, pain, and unspecified dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/01/21, revealed Resident #4 was rarely/never understood and required extensive assistance from two staff members for bed mobility. Resident #4 was assessed to have a functional impairment on one side to an upper extremity. Review of the care plan, dated 05/30/17 and revised on 08/12/21, revealed Resident #4 needed extensive assistance with Activities of Daily Living (ADL) and had a left hand…

    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 · D2021-11-10 · 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 and record review, the facility failed to timely implement dietary recommendations for a resident who had minimal food intake. This affected one (#9) of two residents reviewed for nutrition. The facility identified there were no residents with significant weight loss in the last month. The facility census was 37. Findings include: Record review for Resident #9 revealed the resident was admitted to the facility on [DATE] with diagnoses including hypertension, hyperlipidemia, type two diabetes mellitus, dementia without behavioral disturbances, and cognitive communication deficit. Review of the admission Minimum Data Set (MDS) assessment, dated 08/18/21, revealed Resident #9 had moderately impaired cognition and required extensive assistance from one staff member for eating. Review of the care plan, dated 08/19/21 and revised on 08/23/21, revealed Resident #9 had a nutritional problem or potential nutritional problem. Interventions included to provide and serve a supplement shake as…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-10 · tag F0697 — failed to manage pain — isolated
    Provide 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 observations, staff interviews, and record review, the facility failed to accurately assess a resident's pain. This affected one (#4) of one resident reviewed for pain management. The facility identified 20 residents on a pain management program. The facility census was 37. Findings include: Record review for Resident #4 revealed the resident was admitted to the facility on [DATE] with diagnoses including primary generalized arthritis, pain, and dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/01/21, revealed Resident #4 was rarely/never understood. Resident #4 was on a pain management schedule, did not receive as needed pain medications and was not treated for non-medication interventions for pain. Review of the care plan, dated 07/21/15 and revised on 11/27/19, revealed Resident #4 had the potential for unmanaged pain. Interventions included to administer routine and as needed pain medications as ordered, anticipate the need for pain relief 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2021-11-10 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on employee record reviews and staff interviews, the facility failed to provide a continuing education program and twelve hours of training annually for state tested nursing assistants employed by the facility. This had the potential to affect all 37 residents residing in the facility. Findings include: Review of the personnel file for State Tested Nursing Assistant (STNA) #319 revealed STNA #319 was hired on 02/07/19 and there was no evidence of twelve hours of continuing education in the last year. Review of the personnel file for STNA #350 revealed STNA #350 was hired on 09/28/20 and there was no evidence of twelve hours of continuing education in the last year. Review of the personnel file for STNA #348 revealed STNA #348 was hired on 06/23/16 and there was no evidence of twelve hours of continuing education in the last year. Interview with Human Resources Manager #334 on 11/08/21 at 1:00 P.M. verified she has no evidence of a continuing education program or evidence of 12 hours of training completed annually for any of the STNAs employed by the facility. Interview 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2021-11-10 · 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 observations, interviews, review of the facility's policy, and record reviews, the facility failed to maintain a clean, sanitary kitchen equipment and failed to label and date open food items. This had the potential to affect the 37 residents residing in the facility who all received meals from the kitchen. Findings include: Observation on 11/07/21 at 8:25 A.M. revealed the bottom shelf on the reach in freezer contained a large, thick layer of sticky substance and multiple pieces of unpackaged broccoli. An opened brown paper bag containing tater tots was observed to not be labeled with the date it was opened and was lying on top of the thick layer of sticky substance. Interview with Dietary Personnel (DP) #316 on 11/07/21 at 8:26 A.M. verified there was a large,thick layer of sticky substance and multiple pieces of unpackaged broccoli located on the bottom shelf of the reach in freezer. DP #316 also verified there was an opened brown paper bag containing frozen tater tots which was not labeled with the date it was opened. Observation on 11/09/21 at 10:45 A.M. revealed the…

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

    Nutrition and Dietary 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.

Who owns this facility

Owner / managerTypeRoleSince
BIGHAM, GREGIndividualCORPORATE DIRECTORsince 01/01/2025
BOWERS, KATHYIndividualCORPORATE DIRECTORsince 01/01/2024
CREGO, CURTISIndividualCORPORATE DIRECTORsince 01/01/2022
DAVIS, LARRYIndividualCORPORATE DIRECTORsince 01/01/2025
DIXON, TOMIndividualCORPORATE DIRECTORsince 01/01/2021
SCHIEBER, KIMIndividualCORPORATE DIRECTORsince 01/01/2025
CARDER, NATHANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/03/2019

CMS files one row per role, so the 9 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$4.0M
Net patient revenuemost recent cost report
-12.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 51%Medicare 5%Other / private 44%

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

$307per resident / day
operating cost
$9,318per month
≈ monthly operating cost
$273per 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 366112. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-24, 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.

What to do next