Circleville Post-Acute
1155 Atwater Avenue, Circleville, OH 43113 · For profit - Limited Liability company · 97 certified beds · (740) 477-1695 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)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 5 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 | 0.4% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 3.5% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.6% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 99.7% | 30.1% | 6.5% | worse 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 | 0.3% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 0.0% | 6.1% | 16.1% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 38.9% | 25.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.9% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.4% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.2% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.8% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.4% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 97.7% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.1% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 13.9% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.01 | 1.73 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.71 | 1.80 | 1.80 | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
28.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 88.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 27 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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 | 28.2%CMS range 18.1–37.8 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.8%CMS range 5.5–13.2 | 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 | 88.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 88.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 63.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were 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 | 7.3%CMS range 4.0–14.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 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 97 beds and averages 89.4 residents a day — about 92% 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 3.18 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.79 hrs/resident/day on weekends vs 3.33 on weekdays — 16% thinner on weekends. RN hours go from 0.44 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 35% is below the national median of 45%. 1 administrator has left in the past year.
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.
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.
29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.
- Potential for harm · Dcited beforedisputed · IDR2026-05-13 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake 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 observations resident and staff interviews and review of housekeeping records and review of the facility policy, facility failed to ensure Packaged Thermal Air Conditioner (PTAC) units were maintained in a clean manner. This affected two Residents (#39 and #40) but had the potential to affect all facility residents. The facility census was 90. Findings include: Observation of Resident #39 and #40's PTAC air machine on 05/12/26 at 9:44 A.M., revealed the vents where the air blew out had significant amount of debris including dust and dozens of coin size snack chips.Observation on 05/12/26 at 9:50 A.M. of the main dining areas, revealed three PTAC machines were present and all had thick pieces of dirt and dusty in the vent/grates where the air exited from toward the residents. During an interview on 05/12/26 at 11:51 A.M., Resident #40 stated the PTAC machine gets cleaned sometimes. Observation of Resident #39 and #40's PTAC air machines on 05/13/26 at 8:35 A.M. , revealed the vents where the air blew out had significant amount of debris including dust and dozens of coin size…
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 · F2026-03-16 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy review the facility to serve food at a palatable temperature. This affected all 90 residents in the facility. The facility census was 90. Findings include:Observation on 03/10/26 at 11:35 AM during lunch service revealed individually prepared fruit cups sitting on trays in the kitchen. Temperature of the fruit cups was checked by Dietary Manager #426 at 11:48 A.M. and found the temperature of the fruit cups to be 44 degrees Fahrenheit. Dietary Manager placed trays of fruit cups in the freezer.Interview with [NAME] #154 and [NAME] #248 confirmed they did not check the temperature of the fruit cups prior to lunch tray service and stated, we didn't know we had to.Review of the facility's food temperature logs for 02/23/25 through 03/20/26 revealed cold food items temperatures were checked on day of survey after being prompted and on 02/16/26.Observation on 03/10/26 at 12:56 P.M. during the test tray temperature check revealed fruit cup (peaches) temperature at 63 degrees Fahrenheit.Review of the facility's policy titled, Food…
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 before2026-03-16 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and facility policy review the facility failed to store food in a safe manner, store kitchen utensils in a sanitary manner, prepare and serve food in a sanitary manner and maintain an ice machine in a safe and sanitary manner. This affected all 90 residents. The census was 90. Findings include:1.Observation on 03/09/26 at 6:48 AM on shelving near prep table in kitchen revealed a used 32-ounce bottle of kitchen bouquet browning and seasoning sauce (expiration 07/30/25) and 1 gallon of used white wine (expiration 04/14/25). Interview on 03/09/26 at 7:11 AM with [NAME] #154 confirmed expired items on shelving near prep table.Observation on 03/09/26 at 7:04 AM of the dry storage revealed open container of granulated sugar (lid off to the right side) open container of flour (lid off to the right side), 1 gallon of teriyaki marinade and sauce (unopened, expiration date 06/15/25), seven 32 ounce bottles of kitchen bouquet browning and seasoning sauce (unopened, expiration 07/2025), two bottles of 1 gallon red cooking wine (unopened, expiration 06/2025), two…
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 · Edisputed · IDR2026-03-16 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 personnel file review, staff interview, and facility policy review, this facility failed to provide a verbal abuse free environment for residents. This affected one resident (#75) of the one resident reviewed for abuse with the potential to affect all 71 residents who received care from Certified Nursing Aide (CNA) #114. The facility census was 90. Findings include:Review of the employee personnel record for Certified Nursing Aide (CNA) #114 revealed multiple corrective action forms including poor customer service, unprofessional behavior including being rude and negative towards residents and coworkers. Review of the Employee Counseling Form dated 09/30/2025 revealed CNA #114 failed to maintain respect for a resident. Review of the Employee Counseling Form dated 10/03/2025 revealed CNA #114 failed to maintain respect of a resident related to poor customer service. Review of a typed statement dated 01/14/2026 provided by Licensed Practical Nurse (LPN) #236 revealed, On 01/13/2026, I had to verbally…
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 · Edisputed · IDR2026-03-16 · tag F0609 — failed to report abuse allegations — patternTimely 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 personnel file review, self-reported incident review, staff interview, and facility policy review, this facility failed to report verbal abuse to the required state agency. This affected one resident (#75) of the one resident reviewed for abuse with the potential to affect all 71 residents who received care from Certified Nursing Aide (CNA) #114. The facility census was 90. Findings include:Review of the employee record for Certified Nursing Assistant (CNA) #114 revealed multiple corrective action forms including poor customer service, unprofessional behavior including being rude and negative towards residents and coworkers. Review of the Employee Counseling Form dated 09/30/2025 revealed CNA #114 failed to maintain respect for residents. Review of the Employee Counseling Form dated 10/03/2025 revealed CNA #114 failed to maintain respect of residents related to poor customer service. Review of a typed statement dated 01/14/2026 provided by Licensed Practical Nurse (LPN) #236 revealed, On 01/13/2026, I…
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 · Edisputed · IDR2026-03-16 · tag F0610 — failed to investigate and act on abuse reports — patternRespond 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 personnel file review, self-reported incident review, staff interview, and facility policy review, this facility failed to thoroughly investigate an allegation of verbal abuse. This affected one resident (#75) of the one resident reviewed for abuse with the potential to affect all 71 residents who received care from Certified Nursing Aide (CNA) #114. The facility census was 90. Findings include: Review of the employee record for Certified Nursing Assistant (CNA) #114 revealed multiple corrective action forms including poor customer service, unprofessional behavior including being rude and negative towards residents and coworkers. Review of the Employee Counseling Form dated 09/30/2025 revealed CNA #114 failed to maintain respect for residents. Review of the Employee Counseling Form dated 10/03/2025 revealed CNA #114 failed to maintain respect of residents related to poor customer service. Review of a typed statement dated 01/14/2026 provided by Licensed Practical Nurse (LPN) #236 revealed, On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-16 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and facility record review the facility failed to prepare puree diet to the proper texture. This affected eight residents (#1, #3, #9, #24, #25, #44, #83, and #87) the facility identified as receiving a pureed diet. The census was 90. Findings include:Observation on 03/10/26 at 10:47 AM of lunch tray service revealed the chipped beef and country gravy puree was started. Further observation on 10:51 A.M. with [NAME] #154 revealed [NAME] #154 pouring pureed food into a metal container for service. [NAME] #154 did not taste the puree to check the texture, larger pieces of chipped beef were observed.Interview on 03/10/26 at 10:51 A.M. with [NAME] #154 revealed [NAME] #154 stated, I can go more but that's all the meat pieces will go down. [NAME] #154 did not taste puree to check the texture.Observation on 03/10/26 at 10:51 A.M. with Dietary Manager #426 advised [NAME] #154 to puree the chipped beef and gravy longer. Further observation at 10:56 A.M. revealed a smoother texture.
- Potential for harm · Edisputed · IDR2026-03-16 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to implement an antibiotic stewardship program that included ensuring appropriate antibiotic use. This affected four residents (#59, #68, #69, and #83) of five residents reviewed for antibiotic use. The facility census was 90. Findings include: 1. Review of the record for Resident #68 revealed an admission date of 01/24/26 and diagnoses including dementia, chronic kidney disease, and hypertension. A Minimum Data Set (MDS) assessment completed 01/31/26 documented a brief interview for mental status (BIMS) score of 7, severe cognitive impairment. It indicated the resident was continent of urine and occasionally incontinent of bowel. Review of nursing progress notes dated 03/05/26 at 5:38 P.M. revealed the resident was agitated and tearful today. Obtained urine order. Review of a nursing progress note dated 03/11/26 at 2:26 P.M. revealed urine culture results this shift. Physician notified of results and continued altered mental status.…
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 · Ddisputed · IDR2026-03-16 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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, interview, and facility policy review, the facility failed to ensure Resident #69 was free from physical restraints. This affected one resident (#69) of one resident reviewed for physical restraints. The census was 90. Findings include:Review of Resident #69's medical record revealed an admission date of 03/14/25. Diagnoses included senile degeneration of brain, dementia in other diseases classified elsewhere unspecified severity with agitation, cerebrovascular disease, chronic obstructive pulmonary disease, personal history of urinary tract infections, acquired absence of right leg above knee, essential (primary) hypertension, and bilateral hearing loss.Review of Resident # 69's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 00. Review of Resident #69's functional abilities revealed Resident #69 is dependent on care for toileting hygiene, rolling left to right, sit to lying, chair/bed-to-chair transfer and uses a manual…
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 · D2026-03-16 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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, medical record review, policy review, and staff interview, the facility failed to ensure a resident receiving psychotropic medication was being adequately monitored for response to treatment. This affected one resident (#3) of five residents reviewed for unnecessary medications. The facility census was 90.Findings include:Review of the medical record for Resident #3 revealed an admission date of 01/02/26 and diagnoses including Parkinson's induced psychosis with a history of visual and auditory hallucinations, history of paranoia, and Parkinson's disease with dyskinesia (involuntary and uncontrollable body movements). He was admitted [DATE] with an order for an antipsychotic medication (Pimavanserin 34 milligrams daily) which is used to treat hallucinations and delusions associated with Parkinson's disease psychosis. A Minimum Data Set (MDS) assessment completed 01/09/26 documented a brief interview for mental status score of 11, indicating moderately impaired cognition. The MDS further…
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 19 citations
- Potential for harm · Dcited before2026-03-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, observations, and interviews, the facility failed to notify the physician regarding blood pressure, weight changes and failed to follow physician recommendations for insulin for Resident #92. This affected three residents (#02, #91, #92) out of three residents reviewed for quality of care. The census was 90. Findings include: 1. Review of the closed medical record for Resident #92 revealed the resident was admitted to facility on 06/15/21. Diagnoses included cerebral infarction (CI), type two diabetes mellitus, hyperglycemia, hemiplegia and hemiparesis following CI affecting right dominant side, major depressive disorder, anxiety and history of falls. Review of Resident #92's physician orders dated 01/14/26 revealed Medical Director (MD) #424 ordered Basaglar KwikPen Subcutaneous Solution Pen-injector 100 units per milliliter (ml) (Insulin Glargine) with instructions to inject 25 unit subcutaneously at bedtime (HS) for type two diabetes and Humalog 100 unit/ml (Insulin Lispro)…
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 beforedisputed · IDR2026-03-16 · 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 observation, interview, record review, and policy review the facility failed to properly monitor Resident #42 with a history of exit seeking and wandering. This affected one resident (#42) of one resident reviewed for elopement. The census was 90. Findings include:Review of Resident #42's medical record revealed an admission date of 08/07/23. Diagnoses included Alzheimer's disease, dementia in other diseases classified elsewhere unspecified severity with other behavioral disturbance, restlessness and agitation, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, major depressive disorder and insomnia.Review of Resident #42's care plan dated 08/08/23 and revised on 11/12/24 revealed Resident #42 was at risk for elopement/exit seeking related to dementia, Alzheimer's disease, wanders, oblivious to safety needs noting Resident #42 was on memory care unit. Goals included the resident's safety will not be endangered related to behaviors 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 · D2026-03-16 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and staff interview, the facility failed to ensure resident's blood pressure was measured or obtained per physician orders including not being obtained in the left arm where an arteriovenous shunt/fistula, used for dialysis treatments was located. This affected one resident (#9) of the one resident reviewed for dialysis services. The facility census was 90. Findings include:Review of the medical record for Resident #9 revealed an initial admission date of 10/29/2021 and a re-entry date of 01/14/2022. Diagnoses included end stage renal disease, dependence on renal dialysis, and heart failure. Review of Resident #9's Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating this resident experienced a severely impaired cognition for daily decision-making abilities. Resident #9 was noted to receive renal dialysis services. Review of the plan of care dated 12/27/21 and revised 01/21/26…
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 · D2026-03-16 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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 record review, staff interview and policy review, facility failed to ensure pharmacy recommendations were acknowledged by the physician and addressed in a timely and medically appropriate manner for two residents (#2 and #76). This affected two residents (#2, #76) of five residents reviewed for unnecessary medications. Facility census was 90.Findings include1. Review of the medical record for Resident #2 revealed an admission date of 08/06/25. Diagnoses included Parkinson's disease, vascular dementia, chronic heart failure, above the knee amputation of the right leg and below the knee amputation of the left leg, diabetes, malnutrition and dysphagia. Review of the pharmacy recommendation dated 08/31/25 revealed a recommendation per hospital discharge summary uploaded, allergy to zinc is listed. Please clarify if zinc should be added to allergy list in point click care, (electronic medical record). The recommendation form was acknowledged by the physician on 09/02/25 and marked completed by a facility…
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 · D2026-03-16 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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 record review and staff interview, the facility failed to ensure one resident was free from unnecessary medication when facility administered medications outside of parameters. This affected one resident (#2) of five residents reviewed for unnecessary medications. Facility census was 90. Findings include Review of the medical record for Resident #2 revealed an admission date of 08/06/25. Diagnoses included Parkinson's disease, vascular dementia, chronic heart failure, above the knee amputation of the right leg and below the knee amputation of the left leg, diabetes, malnutrition and dysphagia. Review of the physician orders dated 12/19/25 for Epoetin Alfa Injection Solution 10000 unit/ml with instructions to inject one milliliter subcutaneously once daily every Friday for hemoglobin less than 10 and hold if hemoglobin greater than 10. Review of lab result dated 12/31/25 revealed a hemoglobin result of 10.0. Review of the medication administration record (MAR) dated 01/20/26 revealed the 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.
- Potential for harm · Dcited before2026-03-16 · 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, observations, staff interviews, and facility policy review, the facility failed to maintain contact precautions for residents' with diagnosis of Clostridioides difficile (c-diff) as well as failed to provide proper catheter care. This affected two residents (#66 and #29) of five residents reviewed for infection control. Findings include: 1. Review of the medical record for Resident #29 revealed an admission date of 01/27/2026. Diagnosis included enterocolitis due to Clostridioides difficile, Methicillin resistant Staphylococcus Aureus infection and chronic pain. Review of Resident #29's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating an intact cognition for daily decision-making abilities. Resident #29 was noted to experience impairment to bilateral lower extremities and required the use of a mechanical (Hoyer) lift and wheelchair for transfers and mobility. Resident #29 was dependent…
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 before2025-04-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and policy review, the facility failed to ensure food was protected from contamination. This had the potential to affect all residents in the facility who receive food from the kitchen except for Resident #192 who received nothing by mouth. The facility census was 82. Findings include: Observation and interview on 04/15/25 at 11:50 A.M. revealed [NAME] #185 putting bread into the puree machine with her bare hands. [NAME] #185 was also crumpling the bread in the puree machine with her bare hands. [NAME] #185 stated she doesn't know if she needs to wear gloves. Dietician #444 verified [NAME] #185 should be wearing gloves when touching ready to eat food items. Interview on 04/15/25 at 11:51 A.M. with Assistant Dietary Director #165 stated the puree bread does not go through a cooking process and was served at room temperature. Observation and interview on 04/15/25 at 12:34 P.M. revealed [NAME] #185 was putting together a hamburger on a bun with her bare hands. [NAME] #185 confirmed she grabbed the burger buns with her bare hands to assemble 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 before2025-04-17 · 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 observation, staff interview, and record review, the facility failed to ensure fall interventions were in place for a resident who was at risk for falls and had a history of falls. This affected one (Resident #2) of five residents reviewed for falls. The facility census was 82. Findings include: Review of the medical record for Resident #2 revealed an admission date of 07/03/07. Diagnoses included dementia, osteoarthritis, and a history of falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had cognitive impairment. Resident #2 had impairments on both sides of the upper extremities (UE) and on one side of the lower extremities (LE). Resident #2 required moderate to maximum assistance with all activities of daily living (ADLs). Review of Resident #2's care plan revealed Resident #2 was at risk for falls and had a history of falls. Multiple fall prevention interventions were listed including the use of Dycem on the wheelchair cushion, initiated on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, the facility failed to monitor for mood and behaviors including target behaviors for a resident receiving antianxiety, antidepressants, and antipyshcotic medications. This affected one (Resident #44) of five residents reviewed for unnecessary medications. The facility census was 82. Findings include: Review of Resident #44's medical record revealed Resident #44 was admitted on [DATE]. Diagnoses included vascular dementia, anxiety disorder, restlessness and agitation, schizoaffective disorder - bipolar type, homicidal ideations, psychotic disorder with delusions, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44 was severely cognitively impaired with no signs of psychosis or behaviors noted. Resident #44 received antipsychotic, antianxiety, and antidepressant medications. Review of the active orders for April 2025 revealed Resident #44 was receiving the following medications:…
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 · D2025-04-17 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident and staff interview, and policy review, the facility failed to honor the resident's food requests or preferences and ensure residents received food substitutions for foods they dislike. This affected two (Resident #51 and #72) of three residents reviewed for food preferences. The facility census was 82. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 05/06/22 with diagnoses including but not limited to Alzheimer's disease, dementia, congestive heart failure, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was moderate cognitive deficit. Review of Resident #51's diet order worksheet revealed Resident #51 disliked peas and carrots. Observation and interview on 04/15/25 from 12:40 P.M. to 12:46 P.M. of Resident #51's lunch plate revealed there was not a vegetable on her plate. Resident #51's lunch ticket on 04/15/25 at 12:40 P.M. revealed 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.
- Potential for harm · Dcited before2025-04-17 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake 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 observations, staff and resident interview, and policy review, the facility failed to ensure the resident's hand sinks were working in the resident's room. This affected one (Resident #26) of 25 residents reviewed for physical environment. The facility census was 82. Findings include: Interview and observation on 04/14/25 at 4:24 P.M. with Resident #26 stated he did not have hot or cold water at his hand sink. Resident #26 stated he has not had water at his hand sink for three months and he can only get hot water if he turns on a valve underneath the hand sink. Observation of Resident #26's hand sink revealed there was no water coming from the hand sink. Observation and interview on 04/17/25 at 9:23 A.M. with Maintenance Director #209 confirmed Resident #26's hand sink was not returning hot or cold water. Maintenance Director #209 stated the stim was busted in the sink and he does not have any work orders for this issue. Interview on 04/17/25 at 9:30 A.M. with Certified Nursing Assistant (CNA) #286 confirmed Resident #26's hand sink was not working and it has been an issue…
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 before2022-09-26 · 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
Based on observation, medical record review, review of physician note, staff interviews, and review of facility policy, the facility failed to ensure staff were wearing appropriate personal protective equipment (PPE) when entering a COVID-19 positive Resident #1's room. The facility also failed to ensure appropriate cleaning of a glucometer after blood glucose testing was performed. This had the potential to affect the four residents (#13, #33, #59, and #67) who resided on the 400 hall and had blood glucose testing performed. The facility census was 85. Findings include: 1. Review of Resident #1 medical record revealed an admission date of 05/31/22, with diagnoses including: chronic obstructive pulmonary disease, anemia, multiple sclerosis, and COVID-19. Review of Resident #1 medical record revealed a Physician order dated 09/15/22 for Droplet isolation precautions related to COVID positive every day and night shift until 09/23/22. Observation on 09/21/22 at 8:35 A.M., revealed State Tested Nurse Aide (STNA) #73 going into Resident #1's room. STNA #73 donned a gown and gloves 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 · D2022-09-26 · tag F0644 — isolatedCoordinate 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 record review and staff interview, the facility failed to update the pre-admission screening and resident review (PASARR) for Residents. This affected three (#70, #72, and #80) of five residents reviewed for PASARR. The facility census was 85. Findings include: 1. Record review of Resident #70 revealed an admission date of 10/23/19, with diagnoses including: congestive heart failure, atherosclerotic heart disease, cerebral infarction, dementia, chronic kidney disease, major depressive disorder, bipolar disorder, anxiety disorder, schizophrenia, history of falling, personal history of COVID 19, dysphagia following other cerebrovascular disease, muscle weakness, abnormal posture, need for assistance with personal care, periapical abscess without sinus, disorder of muscle, Parkinson's disease, seizures, anemia, generalized edema, osteoarthritis, idiopathic normal pressure hydrocephalus, functional urinary incontinence, overactive bladder, hypertension, hypothyroidism, burn of second degree of head face…
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 before2022-09-26 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews, the facility failed to ensure a physician ordered treatment was clarified and obtained for a resident with a diabetic ulcer. This affected one (#286) of one resident reviewed for non pressure ulcer. The facility census was 85. Findings include: Review of Resident #286's medical record revealed an admission date of 09/05/22, with diagnoses including: osteomyelitis, cellulitis of the left lower limb, type two diabetes mellitus, morbid obesity, and osteoarthritis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition. The resident was assessed to require extensive assistance from one staff member for toileting, supervision for bed mobility and transfers, and to be independent with setup help only for eating. The resident was assessed to have a diabetic ulcer of the foot. Review of the active care plans revealed there was not a care plan in place for the diabetic ulcer to the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-26 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, resident and staff interview, the facility failed to assist the resident in making appointments for hearing aides. This affected one (#38) of three residents reviewed for ancillary services. The facility census was 85. Findings include: Review of Resident #38's medical record revealed an admission date of 05/20/10 and re-admission date of 06/18/14. Diagnoses for Resident #38 included: chronic obstructive pulmonary disease, contact with and exposure to COVID-19, respiratory failure, morbid obesity, obstructive sleep apnea, type two diabetes mellitus, symbolic dysfunction, heart failure, carcinoma of bronchus and lung, protein calorie malnutrition, dysphagia phase, abnormal posture, staphylococcus, acute ischemic heart disease, gout, anxiety disorder, pneumonia, unsteadiness on feet, encephalopathy, peritoneal abscess, muscle weakness, allergic rhinitis, hypokalemia, diabetes mellitus type two with diabetic neuropathy, sepsis, abnormal weight loss, acute and chronic respiratory failure with hypercapnia, hyperlipidemia, insomnia, osteoarthritis, major depressive…
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 before2022-09-26 · 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
Based on record review, resident and staff interviews, the facility failed to ensure the shower chair brakes were locked for a resident who required assistance, resulting in a fall. This affected one (#52) of two residents reviewed for falls. The facility census was 85. Findings include: Review of Resident #52s medical record revealed an admission date of 01/30/22, with diagnoses of: acute respiratory failure, chronic respiratory failure, chronic pulmonary disease, morbid obesity, type two diabetes mellitus with diabetic neuropathy, acute upper respiratory infection, history of COVID-19, cellulitis of limb, dysphagia pharyngeal, cardiomyopathy, osteopenia and congestive heart failure. Review of the 05/06/22 quarterly assessment revealed the Resident is moderately cognitively impaired and required extensive assistance for toilet use and limited assistance for personal hygiene, dressing, bed mobility and transfer. The resident required physical help in bathing and one person physical assist. The Resident uses a walker and wheelchair to aid in mobility and is occasionally incontinent…
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 · D2022-09-26 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record reviews, the facility failed to ensure medication was available and administered as ordered by the physician. This affected one (#42) of five residents reviewed for unnecessary medications. The facility census was 85. Findings include: Record review for Resident #42 revealed this resident was admitted to the facility on [DATE] and had diagnoses including hypertension, schizoid disorder, unspecified dementia with behavioral disturbances, anxiety disorder, mood disorder, and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/22/22, revealed the resident had moderately impaired cognition. The resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting, and supervision for eating. Review of the physician's order, dated 07/25/22, revealed an order to administer 7.5 milligram (mg) tablet and one mg of Olanzapine (an antipsychotic medication) once a day for schizoid…
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 · D2022-09-26 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record reviews, observations, and staff interviews, the facility failed to ensure the medication error rate was less than five percent, as evidence by six medication errors out of 26 opportunities observed, resulting in 23.07 % (percent) medication error rate. This affected two (#57 and #77) of three residents observed for medication administration. The facility census was 85. Findings include: 1. Review of Resident #77's medical record revealed an admission date of 04/03/15, with diagnoses including: chronic congestive heart failure, venous insufficiency, conjunctivitis, atrial fibrillation, and history of COVID-19. Review of a Physician Order for Resident #77 dated 02/08/21, revealed an order for Artificial Tears Solution 1.4 % (Polyvinyl Alcohol), instill two drops in both eyes three times a day for dry eyes. Observation on 09/21/22 at 7:45 A.M. , of the medication administration pass with Certified Medicine Aide (CMA) #1 revealed Resident #77 received medications including: amiodarone, colace, eliquis, lasix, gabapentin, losartan, metoprolol, multi-vitamin, 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 · D2022-09-26 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review, and review of facility policy, the facility failed to ensure accurate documentation of medication administration. This affected one (#42) of five residents whose medications were reviewed during the annual survey. The facility census was 85. Findings include: Record review for Resident #42 revealed this resident was admitted to the facility on [DATE] and had diagnoses including hypertension, schizoid disorder, unspecified dementia with behavioral disturbances, anxiety disorder, mood disorder, and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/22/22, revealed the resident had moderately impaired cognition. The resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting, and supervision for eating. Review of the physician's order, dated 07/25/22, revealed an order to administer 7.5 milligram (mg) tablet and one mg of Olanzapine (an antipsychotic 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.
“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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- 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.
Part of a chain
This home belongs to PACS GROUP — 274 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.9 | -0.9 vs chain |
| Health inspection | 3 of 5 | 2.5 | +0.5 vs chain |
| Staffing | 1 of 5 | 2.5 | -1.5 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 273 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 273; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PROVIDENCE GROUP INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/07/2019 |
| CHERNICK, EDWARD | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 02/01/2022 |
| DUTIEL, BRIAN | Individual | W-2 MANAGING EMPLOYEE | — | since 04/25/2024 |
| APT, FREDERICK | Individual | CORPORATE OFFICER | — | since 02/10/2021 |
| JERGENSEN, JOSHUA | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| MITCHELL, JOHN | Individual | CORPORATE OFFICER | — | since 02/10/2021 |
1 organizational owner 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.
This home reported $290K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 365456. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-16, 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.