Cedarwood Plaza
12504 Cedar Road, Cleveland Heights, OH 44106 · For profit - Corporation · 115 certified beds · (216) 371-3600 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,171 in federal fines (most recent 2024-05-15)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (58%) runs well above the national median (45%)
- its last standard health inspection was over 3 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 3.1% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 4.5% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.8% | 0.4% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 60.6% | 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 | 0.8% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.3% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 6.0% | 25.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.8% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 30.7% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.7% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 77.5% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 21.1% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 5.8% | 12.9% | 12.0% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
47.0% 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 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% 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 | 47.0%CMS range 31.6–64.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.3–15.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 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 115 beds and averages 103.3 residents a day — about 90% occupied, or roughly 12 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 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 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 3.26 hrs/resident/day on weekends vs 3.90 on weekdays — 16% thinner on weekends. RN hours go from 0.64 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% is well above 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.
This trend is not current. The most recent of these two inspections was over 3 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-05-15 · 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, resident and staff interview, review of a police report and review of facility policy, the facility failed to provide a safe environment free from a potential accident hazard when State Tested Nursing Assistant (STNA) #563 was found to have an unsecured loaded firearm in the facility. This resulted in Immediate Jeopardy and potential for serious life-threatening harm when STNA #563 left a loaded firearm, with additional rounds of ammunition, wrapped in a fleece vest and in a clear plastic bag, unsecured on a cart on the 3 North Hallway where residents resided and had access to the bag. Resident #64 subsequently took the bag containing the loaded firearm to her room, without staff knowledge, found the firearm, and placed it under the mattress of her bed. This affected one (#64) resident and had the potential to affect all 108 residents residing…
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 before2025-10-14 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observation, interviews and facility policy review, the facility failed to ensure Residents #9, #35 and #36 received a two-gram sodium (low sodium) and/or cardiac diet as ordered. This affected three residents (#9, #35, and #36) out of four residents reviewed for therapeutic diets but had the potential to affect an additional six residents (#3, #7, #42, #54, #70, and #84) the facility identified as being on a two-gram sodium and/or a cardiac diet. The facility census was 102. Findings include:1. Review of the medical record for Resident #9 revealed an admission date of 01/07/25. Pertinent diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), respiratory failure, hypertension (HTN), and hyperlipidemia. Review of the physician orders for Resident #9 revealed an order dated 03/27/25 for a low sodium, regular texture, thin consistency, two-gram sodium diet. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9…
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 before2025-10-14 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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 observations, interviews, record reviews, review of facility menus and facility policy review, the facility failed to ensure the zucchini and onions were palatable and served at a preferred temperature and failed to ensure the noodles were palatable for lunch on 10/08/25. This affected five residents (#5, #29, #41, #60, and #100) out of five residents reviewed for meal palatability but had the potential to affect an additional 94 residents the facility identified as receiving meals from the kitchen. The facility identified three residents (#21, #43, and #55) as not receiving meals from the kitchen. The facility census was 102. Findings include:1. Observation on 10/08/25 at 11:48 A.M. of Dietary [NAME] #311 taking the temperatures of meal items in the steam table revealed the parsley noodles were 161.3 degrees Fahrenheit (F), the baked chicken was 130.4 degrees F, the mushroom gravy was 157.9 degrees F, the zucchini and onions were 169.1 degrees F. Observation of the items on the steam table revealed the noodles appeared to seasoned with dried herbs, the chicken appeared to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-10-14 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, food temperature log review and facility policy review, the facility failed to ensure the mechanical soft chicken was held at a safe holding temperature for lunch on 10/08/25, which had the potential to affect 18 residents (#3, #4, #8, #10, #11, #15, #20, #22, #30, #42, #45, #52, #61, #63, #69, #82, #93, and #99) the facility identified as receiving a mechanical soft diet. The facility census was 102. Findings include:Review of the facility Food Temperature Log, dated 10/08/25, revealed all regular, mechanical and puree items for lunch had been cooked to safe internal temperatures with the regular texture chicken 179 degrees Fahrenheit (F), the noodles 169 degrees F, zucchini and onions 169 degrees F, mechanical soft chicken 176 degrees F, mechanical soft zucchini and onions 168 degrees F, puree chicken 174 degrees F, puree noodles 174 degrees F, and the puree zucchini and onions 169 degrees F. Observation on 10/08/25 at 11:48 A.M. of Dietary [NAME] #311 taking the food temperatures of the food items on tray line revealed the following concerns:…
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 before2025-10-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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, interview, review of infection surveillance logs and review of facility policy, the facility failed to ensure catheter care was performed per appropriate standards of practice to mitigate the potential for contamination and urinary tract infection. This affected one resident (#6) of one resident reviewed for catheter care and had the potential to affect four additional residents (#2, #49, #59, and #90) who the facility identified as having indwelling urinary catheters. The facility census was 102. Findings include:Review of the medical record for Resident #6 revealed an admission date of 11/12/24 with diagnoses including paranoid schizophrenia, arthritis due to bacteria right hip, hemiplegia or hemiparesis following cerebral infarction affecting right dominant side and left non-dominant side, paraplegia, slow transit constipation, benign prostatic hyperplasia without lower urinary tract symptoms, and neuromuscular dysfunction of the bladder. Review of the physician's order…
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 before2025-10-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews, hospital record review and facility policy review, the facility failed to timely address a significant weight loss for Resident #104. This affected one resident (#104) out of three residents reviewed for nutrition. The facility census was 102. Findings include:Review of the closed medical record for Resident #104 revealed an admission date of 08/22/23 and a discharge date of 09/04/25. Pertinent diagnoses included schizophrenia, severe sepsis with septic shock, adrenocortical insufficiency (a condition when adrenal glands don't make enough of the hormone cortisol with weight loss being one of the symptoms), other diseases of plasma-protein metabolism, depression, thyrotoxicosis (a condition when there is too much thyroid hormone in the body with unexplained weight loss being one of the symptoms) with diffuse goiter. Review of Resident #104's care plan initiated on 08/29/23 revealed the resident had altered nutritional status related to thyroid disorder, schizophrenia,…
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 before2025-10-14 · 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
Based on record review, observation, interview and review of the facility policy, the facility failed to ensure proper infection control procedures were followed during care for Resident #6, including appropriate donning and doffing procedures with use of personal protective equipment (PPE), appropriate catheter care, and proper handling of soiled linen and other soiled items. This affected one resident (#6) of one resident reviewed for catheter care and had the potential to affect all 16 residents (#6, #10, #19, #28, #31, #33, #43, 348, #56, #63, #68, #71, #75, #78, #98, and #102) who resided on the North unit of the second floor. The facility census was 102. Findings include:Review of the medical record for Resident #6 revealed an admission date of 11/12/24 with diagnoses including paranoid schizophrenia, arthritis due to bacteria right hip, hemiplegia or hemiparesis following cerebral infarction affecting right dominant side and left non-dominant side, paraplegia, slow transit constipation, benign prostatic hyperplasia without lower urinary tract symptoms, and neuromuscular…
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 before2025-08-30 · 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 observation, staff interview, and policy review, the facility failed to maintain the kitchen in a clean and sanitary condition. This had the potential to affect all 104 residents residing in the facility. The facility census was 104.Findings include:Observation of the kitchen area with Dietary Aide (DA) #750 on 08/30/25 beginning at 9:02 A.M. revealed the following that was verified at the time of discovery.Observation of the walk-in cooler revealed a spiral ham with no date, an onion chopped in half and stored in plastic wrap with no date, a large plastic container of diced turkey with no date, a metal container with butter that had no label or date, a metal container of bacon bits with no label or date, and a large plastic container of fat from the preparation of a beef roast with no label or date. Observation of the walk-in freezer revealed a box of beef slabs which was opened and the slabs of beef were sitting on the cardboard box and not in a plastic bag or any sort of container. The exposed beef slabs showed signs of significant freezer burn. Further observation of 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 · F2025-08-30 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based observation and staff interview, the facility failed to maintain its dumpster area in a clean and sanitary condition. This had the potential to affect all 104 residents residing in the facility. The facility census was 104.Findings include: Observation of the outside dumpster area with Dietary Aide (DA) #750 on 08/30/25 beginning at 9:45 A.M. revealed to the left of the dumpster area, outside of the physical dumpster, were significant amounts of debris, including plastic gloves, used plastic silverware, paper plates (many with noticeable food residue), brown bags, and various other pieces of plastic laying around. In front of the dumpster, approximately fifteen feet away, was a cardboard box on the ground and the box appeared to have been run over multiple times by vehicles. To the right of the dumpster was the facility's grease barrel, used to store excess oil and grease from the kitchen, and it was observed to be open to the air with a stock pot of water placed on top of it.Interview with DA #750 on 08/30/25 confirmed the above findings of the outside dumpster area at 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 · Fcited before2025-07-01 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews, the facility failed to ensure the correct serving sizes and all menu items were provided per the menu. This affected four residents (#28, #43, #55, and #99) but had the potential to affect all residents, except two residents (#36 and #51) who received nothing by mouth. The facility census was 101. Findings include: Interviews on 07/01/25 between 9:44 A.M. and 1:18 P.M. with Residents #28, #55, and #99 revealed they received small portions at mealtimes, but also stated they never knew what was on the menu prior to receiving meals. Review of the menu revealed lunch for 07/01/25 was deli meat and cheese sandwich, creamy coleslaw, and four ounces (oz) of cinnamon apple slices. Residents on a pureed diet were to get pureed soft, cooked vegetables servings size was #12 scoop (green handle which provides a 2.7 oz portion) and pureed cinnamon apple slice serving size was a #10 scoop (three oz). Residents on a mechanical soft diet were to receive ground deli meat and cheese using a #8 scoop (four oz). Observations on 07/01/25 between 12:20…
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 before2025-07-01 · 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 record review, the facility failed to dry silverware and serve food in a sanitary manner. This had the potential to affect all residents except two (#36 and #51) who received nothing by mouth. The facility census was 101. Findings include: Observations on 07/01/25 at 12:19 PM observed Dietary Aide (DA) #409 using a dish cloth to dry the silverware that was in a tray sitting on the end of the steam table. DA #409 proceeded to place the silverware after drying them in a silverware holder. DA #409 verified the observation and stated she didn't know they weren't supposed to dry them that way. Observations on 07/01/25 at 12:20 P.M. of the lunch tray line revealed a large pan of sliced deli meat sitting on the steam table (not in an ice bath), next to it was a large pan of lettuce, and a large pan of sliced tomatoes. [NAME] #555 tore open a loaf of white bread while wearing gloved hands, grabbed slices of bread, grabbed two slices of deli meat, folded it over onto the bread and proceeded to grab lettuce and tomato slices and place onto one slice 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.
Show the remaining 19 citations
- Potential for harm · Fcited before2025-02-25 · 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 and interview, the facility did not ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 111 residents receiving meals from the kitchen excluding Resident #36 and #51 who the facility identified as eating nothing by mouth. The facility census was 113. Findings include: An observation was conducted on 02/25/25 from 12:35 P.M. to 1:33 P.M. with Dietary Manager (DM) #503 of the facility kitchen. In the main freezer there was bread stored in a clear plastic bag with no label or dates, and an open bag of French fries in a clear plastic bag with no label or date on it. Observation of the dry food storage area revealed an open, two-pound bag of powdered sugar that was wrapped in ripped plastic wrap without a date or label and the powdered sugar was spilling out of the bag when it was picked up to check for a label and date. Pumpernickel bread and sausage buns were observed with no dates or labels on the bread items. A 55 ounce bag of tortilla shells were observed on the bread shelf with a use by date of 12/13/24.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-25 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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 review of facility policy, the facility did not ensure palatable food was served to all residents receiving meals from the kitchen. This affected six residents (#24, #28, #29, #32, #43 and #87) of six residents reviewed for food service. The facility census was 113. Findings include: An observation was conducted on 02/25/25 at 12:35 P.M. to 1:33 P.M. of the kitchen food production, kitchen environment and lunch tray line meal service. The lunch consisted of chicken cutlet, spinach, chocolate chip cake and substitutes available were hamburger or ham slices, mixed vegetables, potato salad and ice cream. All hot foods on tray line reached acceptable temperature above 165 degrees Fahrenheit ( F) prior to the start of meal service. A second set of temperatures were not taken to monitor the temperatures of the food on tray line throughout the observation. A test tray was requested as the last resident's food was plated and ham slice, potato salad and mixed vegetables were placed for the test tray. The food cart left the kitchen at 1:33 P.M. with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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, resident and staff interviews, record review, and facility policy review, the facility failed to provided timely incontinence care to the residents. This affected two (Residents #10 and #74) of three residents reviewed for incontinence care. The facility census was 110. Findings include: 1. Record review for Resident #10 revealed an admission date of 11/06/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and muscle weakness. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was moderately cognitively impaired. Resident #10 had impairment on one side of the upper and lower extremities, was frequently incontinent of urine and always incontinent of bowel. Resident #10 required substantial/maximal assistance with toileting hygiene, personal hygiene, and was dependent on staff for transfers. Review of the care plan dated 12/23/24 revealed Resident #10 had bowel incontinence due to impaired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-27 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when caring for a resident on the South unit who had orders for Enhanced Barrier Precautions (EBP). This affected one Resident (Resident #51) of three residents reviewed for infection control, and had the potential to affect an additional 23 residents (#33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #52, #53, #54, #55 and #56) living on the South unit. The facility identified 24 residents in EBP (Residents #4, #10, #11, #14, #20, #27, #30, #31, #33, #41, #47, #48, #50, #51, #52, #54, #58, #75, #81, #86, #87, #88, #97, and #103). The facility census was 106. Findings include: Review of the medical record for Resident #51 revealed an admission date of 02/23/24. Diagnosis included type two diabetes mellitus, anoxic brain damage, urinary tract infection, acute respiratory failure with hypoxia, infection 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 · Fcited before2024-03-07 · 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 items were stored and prepared in a safe and sanitary manner. This had the potential to affect all 101 residents residing in the facility. The facility census was 101. Findings Include: A tour of the facility kitchen was completed on 03/06/24 between 8:15 A.M. and 8:33 A.M. with Dietary Manager #200. Observation of the walk-in cooler revealed a box containing approximately six raw carrots and noted the carrots to be significantly brown in color with significant areas of rot on them, a large box of green peppers with soft exterior skins and numerous other peppers were discolored with various areas of brown and black rot, and a bag of fresh heads of lettuce with significant areas of rot and brown spots on the lettuce. Observation of the walk-in freezer revealed a bag of chicken breast was significantly freezer burned and a frozen chuck roast was noted on the floor. Observation of the food preparation areas revealed there were approximately five burners on the kitchen stove that were incased in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-14 · 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, and facility policy review the facility failed to ensure proper physical assistance was provided to prevent a fall. This affected one resident (#107) of three residents reviewed for falls. Findings include: Review of the medical record for Former Resident #107 revealed an admission date of 10/06/22. Diagnoses included epilepsy, hemiplegia, and hemiparesis following cerebral infarction, acquired absence of left leg above knee, and acquired absence of right leg below knee. The resident was discharged to the hospital on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #107 had intact cognition. The resident had the behavior of rejection of care. Functional Abilities: used a wheelchair, no impairment upper extremities, impairment on one side lower extremities. Review of the plan of care dated 10/20/22 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.
- Potential for harm · Fcited before2023-09-28 · 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 observations, interview, and facility policy review the facility failed to ensure that the kitchen was clean and sanitary. This had the potential to affect 95 residents who consumed meals from the facility's kitchen. Residents (#1, #6, #27, #46, #85, and #87) were identified as receiving nothing by mouth. The facility census was 101. Findings include: During the initial tour of the kitchen on 09/25/23 from 8:15 A.M. to 8:35 A.M. revealed that the slicer had dried beef on it, the mixer had dried food splatter on the back splash, tomato soup and ham salad was not labeled or dated in the walk-in refrigerator, and pizza crust was not wrapped properly, labeled, or dated in the walk-in freezer. Observation on 09/27/23 at 7:40 A.M. revealed [NAME] #801 was not wearing a beard net. Dietary Manager (DM) #802 verified that [NAME] #801 was not wearing a beard net and got one for [NAME] #801. During tray line observation on 09/27/23 at 9:49 A.M. revealed [NAME] #801 used his gloved hand to take the biscuits out of the pan and cut them in half for the sausage gravy then proceeded to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-28 · 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 — an excerpt from the official record, may be distressing
Based on observation, interview, and taste test the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected five residents (#8, #26, #42, #55, and #94) who were prescribed pureed diets of 95 residents who consumed meals from the facility's kitchen. Residents (#1, #6, #27, #46, #85, and #87) were identified as receiving nothing by mouth. The facility census was 101. Findings include: Observation on 09/27/23 at 11:28 A.M. with [NAME] #880 revealed pureed yellow squash that was not proper consistency. [NAME] #880 put some pureed squash in a portion control cup for taste test, then put the pan in the oven to keep warm and took the robot coupe to the dish machine for cleaning. Taste test revealed that the pureed squash had chunks of squash in it and was not pureed properly. Dietary Manager (DM) #802 was asked to taste pureed squash. DM #802 tasted the pureed squash and stated that it had to be pureed more. Observation on 09/27/23 at 11:37 A.M. [NAME] #880 proceeded to puree roast beef and then portioned two soufflé cups with purred beef. Taste…
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 · D2023-09-28 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure call lights were within reach and accessible for Resident #23 and Resident #29. This affected two residents (#23 and #29) of 101 residents reviewed for call light placement. Findings include: 1. Record review revealed Resident #23 was admitted to the facility on [DATE] with a readmission date of 06/23/22 with diagnoses including aphasia, bipolar disorder, rhabdomyolysis, chronic obstructive pulmonary disease, and unspecified convulsions. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was cognitively intact and required extensive assistance of one staff for mobility, total dependence with two staff for transfers, and extensive assistance with two staff for toilet use. Observation of Resident #23 on 09/25/23 at 10:08 A.M. revealed Resident #23 was lying in bed and his call light was lying on the floor. The call light was noted to be out of reach of Resident #23. Review of the care…
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 · D2023-09-28 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review the facility failed to ensure Resident #33's advance directives were correct in the medical record. This affected one resident (#33) of 29 residents reviewed for advanced directives. The facility census was 101. Findings Include: Review of the medical record for Resident #33 revealed the electronic charting revealed the resident was a full code. Review of the physician's orders revealed Resident #33 had an order for full code. Review of the hard chart revealed a Do Not Resuscitate (DNR) form dated 04/21/23. Interview on 09/25/23 at 9:50 A.M. with Licensed Practical Nurse (LPN) #820 verified the electronic charting had Resident #33 advance directive as a full code and the hard chart had an advance directive form stating Resident #33's code status was DNR. LPN #820 verified the two-code statuses did not match.
- Potential for harm · Dcited before2023-09-28 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, interview, and facility policy review the facility failed to ensure therapeutic diets were provided to residents. This affected one resident (#30) of six residents reviewed for nutrition services. The facility census was 101. Findings include: Record review of Resident #30 revealed he was admitted to the facility 06/17/20 with diagnoses including stage five chronic kidney disease, end stage renal disease with dialysis dependence, and type two diabetes. Had had an order dated 10/24/21 to receive a renal diet (a diet specific for residents with renal complications, including limiting intake of minerals such as phosphorus and potassium). Observation of a meal pass on 09/27/23 at 8:22 A.M. revealed Resident #30 was served a tray including a carton of orange juice, which he consumed during the meal. His meal ticket acknowledged he was on a renal diet and was to receive cranberry juice as his juice for the meal. Interview with Dietitian #802 on 09/27/23 at 8:39 A.M. revealed orange juice was not appropriate for residents on renal diets due to its high…
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 · D2023-09-28 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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, staff interview, and facility policy review the facility failed to ensure residents who required continuous tube feeding received uninterrupted administration of enteral formula. This affected two residents (#46 and #87) of two residents reviewed for tube feeding. The facility identified six residents (#1, #6, #27, #46, #85, #87) who received no food by mouth and three residents (#55, #62, #94) who received supplemental tube feed. The facility census was 101. Findings include: 1. Record review revealed Resident #46 was admitted to the facility on [DATE] with a readmission date of 07/12/18 with diagnoses including diabetes mellitus, dysphagia, encounter for attention to gastrostomy, and unspecified convulsions. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was rarely understood and required extensive assistance of two staff for activities of daily except eating required extensive assistance with one staff. Review of 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 · D2023-09-28 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure blood laboratory orders were carried out appropriately. This affected one resident (#79) of five residents reviewed for unnecessary medications. The facility census was 101. Findings include: Record review of Resident #79 revealed he was admitted to the facility 10/06/22 with diagnoses including epilepsy, congestive heart failure, hemiplegia, and hypothyroidism. He had an order in place for monthly blood draws starting on 12/28/22. He was on several scheduled medications including diuretics, anti-hypertensives, and anticoagulants. A note by Clinical Nurse Practitioner (CNP) #900 dated 09/11/23 said she was adding a lab draw for blood count, metabolic panel, and thyroid-stimulating hormone for 09/12/23. Review of Resident #79's lab draw records revealed the lab on 09/12/23 was marked as unable to obtain. Review of the notes revealed no evidence the lab draw was rescheduled, or the missed draw was reported to the nurse practitioner. Interview with Licensed Practical Nurse (LPN) #888 on 09/27/23 at 11:18 A.M. 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.
- Potential for harm · F2020-03-12 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to employ a qualified dietitian. This affected all 110 facility residents. Findings include: Review of the record of Resident #74 revealed she was admitted to the facility on [DATE] with diagnoses including heart failure, diabetes mellitus, chronic kidney disease, dementia, and chronic obstructive pulmonary disease. The resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], and most recent significant change MDS dated [DATE], both revealed the resident was cognitively impaired and was dependent on staff for eating and her other activities of daily living. The resident also had impaired skin areas. Review of the care plan for nutrition dated 08/29/2008, and updated through 05/19/2020, revealed the resident was at risk due to her medical diagnoses. Interventions included encouraging oral and fluid intake, provide supplements per dietitian recommendation and physician order, and monitor for signs of dehydration. Review of a dietitian note dated…
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 · D2020-03-12 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the accuracy of the assessments. This affected two (Residents #350 and #99) of 30 resident records reviewed for assessments. The facility census was 110 residents. Findings include: 1. Review of the record revealed Resident #350 was admitted to the facility on [DATE] with diagnosis including Parkinson's disease, vascular dementia, epilepsy, muscle weakness, and difficulty walking. Review of fall investigations revealed Resident #350 had a fall on 10/01/2019, 10/19/2019, 11/14/2019, and 11/18/2019. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #350 had only one fall with no injury since admission/prior assessment. Interview with Licensed Practical Nurse #405 verified the annual MDS Section J for falls done on 12/16/2019 was incorrect. 2. Review of the medical record revealed Resident #99 was admitted to the facility on [DATE] with diagnosis including pneumonia and chronic obstructive pulmonary disease. 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 before2020-03-12 · 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, record review, and interview, the facility failed to ensure that interventions were put into place to prevent falls. This affected one (Resident #350) of four resident records reviewed for falls. The facility census was 110 residents Findings include: Review of the record revealed Resident #350 was admitted to the facility on [DATE] with diagnosis including Parkinson's disease, vascular dementia, epilepsy, muscle weakness, and difficulty walking. Review of his care plan dated 10/22/2006 revealed Resident #350 was at risk for potential falls/injuries related to physical impairments, history of falls, impaired mobility, impaired balance, unsteady gait, cognitive impairment, poor safety awareness, and hemiplegia. Review of his annual Minimum Data Set assessment dated [DATE] revealed he was severely cognitively impaired and required extensive assistance with one to two staff members for his activities of daily living. Review of unwitnessed fall report dated 11/14/2019 revealed Resident #350 had…
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 · D2020-03-12 · 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 and interview, the facility failed to ensure pharmacy consultations were reviewed and addressed by the physician in a timely manner. This affected one (Resident #13) of five residents reviewed for unnecessary medications. The facility census was 110 residents. Findings include: Review of the record revealed Resident #13 was admitted to the facility on [DATE] with diagnosis which included hypertensive heart, chronic kidney disease without heart failure, chronic obstructive pulmonary disease, schizophrenia, anxiety, and major depressive disorder. Review of the consultant pharmacist interim reviews done on 06/14/2019 revealed the pharmacist recommendations to ensure the resident has an appropriate psychiatric diagnosis for the antipsychotic Seroquel; evaluate the risk versus benefit of continuing the medication amitriptyline and to attempt using lowest effective does if to be continued; and to consider decreasing the medication escitalopram from 20 milligrams to 10 milligrams. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-01-31 · tag F0582 — isolatedGive 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 interview and beneficiary notice review, the facility failed to provide Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNABN) CMS 1055 notices to two of two Residents (#42 and #49) who were notified their skilled services would end and would be remaining in the facility of three Residents (#42, #49, and #306) reviewed for beneficiary protection notification. The facility census was 107. Findings include: Review of the beneficiary protection notifications for Resident's #42, #49 and #306 revealed Resident's #42 was notified her skilled services were ending on 11/21/18, Resident #49's would end on 12/20/18, and Resident #306 discharged to home. This notice was provided on the Notice of Medicare Non-Coverage (NOMNC) CMS 10123, a generic form. Both residents chose to remain in the facility. There was no evidence the required SNABN form was provided which would have indicated the cost to continue to privately pay for the skilled services if they would choose. Interview with Licensed Social Worker (LSW) #41 on 01/29/19 at 2:15 P.M. verified she provided the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-01-31 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to provide meals that were palatable and at an appropriate serving temperature. This affected one (Resident #86) of five residents reviewed for food complaints and had the potential to affect eight residents (Residents #18, #38, #50, #61, #86, #95, #105, and #109) on a pureed diet. The facility census was 107. Findings include: Review of the record revealed Resident #86 was admitted on [DATE] with diagnoses including pneumonia, diabetes, and dysphagia (difficulty swallowing). The resident had a physician order dated 01/08/19 for regular diet, pureed texture and nectar consistency fluids. Review of the Minimum Data Set (MDS) 3.0 admission assessment indicated the resident had severe cognitive impairment, had a mechanically altered diet, and needed extensive assistance with eating. During an interview on 01/28/19 at 9:40 A.M., Resident #86 indicated he was on a pureed diet. He complained that the food was too thick and did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,171 in federal fines across 1 penalty.
- $8,171 — penalty dated 2024-05-15
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to LEGACY HEALTH SERVICES — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.5 | -0.5 vs chain |
| Health inspection | 2 of 5 | 2.7 | -0.7 vs chain |
| Staffing | 2 of 5 | 2.2 | -0.2 vs chain |
| Quality measures | 5 of 5 | 4.9 | ≈ chain avg |
The other 9 homes this chain runs (chain average 3.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| OH 10 HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/06/2022 |
| CC OH10 OPCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| CHAVOS221 HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| CHAVOS221 IRRV TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| LIONSVIEW OPCO NR LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| LIONSVIEW SC LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| LIVING26 HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| LIVING26 IRRV TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| SAPPHIRE143 HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| SAPPHIRE143 IRRV TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/06/2022 |
| STUMP, BARRY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 05/07/2019 |
| SHARVIT, ELIAV | Individual | CORPORATE OFFICER | — | since 06/22/2007 |
CMS files one row per role, so the 13 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
10 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365033. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-09-28, 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.