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Hillside Plaza

18220 Euclid Ave, Cleveland, OH 44112 · For profit - Corporation · 47 certified beds · (216) 486-6300 Medicare & Medicaid certified

Call the home — (216) 486-6300 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609, F0610) — most recent Nov 2024
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • 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 facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (66%) runs well above the national median (45%)

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS
Urgent care / clinic
3353 Hollister Rd · (216) 233-0080 · Call to confirm hours
Pharmacy
20485 Euclid Ave · (216) 531-1466 · Call to confirm hours
Grocery
18235 Euclid Ave · (216) 481-1180 · Call to confirm hours
Park
Avalon Rd &, Olympia Rd · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5

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

Trend — is this home getting better or worse?

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

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased0.0%5.3%15.4%check this — see note marked star below the table
Long-stay residents who lose too much weight5.3%6.2%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms53.2%30.1%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.0%3.2%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened0.0%6.1%16.1%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication12.4%25.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers6.5%3.4%4.7%worse
Long-stay residents with worsening bladder/bowel control8.4%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table2.7%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.4%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine95.2%75.6%79.4%better

* 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.

0.34U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 58% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.88
RN hours/ resident / day
1.29
LPN hours/ resident / day
1.85
Aide hours/ resident / day
4.02
Total nurse hours/ resident / day
0.38
RN hoursweekends
66.0%
Total nursing turnover
77.8%
RN turnover

How full it usually is: this home is certified for 47 beds and averages 38.9 residents a day — about 83% occupied, or roughly 8 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.02 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 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 3.14 hrs/resident/day on weekends vs 4.38 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 1.08 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 66% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

5
deficiencies at the latest standard inspection (2025-05-19)
8
at the previous standard inspection (2022-07-20)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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 · D2025-09-08 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 record review, interviews, and facility policy review, the facility failed to ensure documentation for medication administration was completed timely. This affected one resident (#10) out of three resident records reviewed for medication administration. The facility census was 38.Findings include:Review of the medical record for Resident #10 revealed an admission date of 03/13/25. Diagnoses included but were not limited to osteomyelitis of vertebra sacral and sacrococcygeal region, chronic osteomyelitis, injury at T7 - T12 thoracic spinal cord, sepsis, and paraplegia.Review of the quarterly MDS dated [DATE] revealed Resident #10 had intact cognition. Review of Resident #10's Medication Administration Record (MAR) in the electronic medical record for July 2025 revealed Cymbalta DR Particles 30 milligram (mg) give 1 capsule daily had blank spot not signed for (indicating the medication had not been received) for 7/16/25. Melatonin 3 mg give 1 tablet daily had a blank spot for 7/10/25 and 7/16/25. Bactrim…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-05-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review and review of the facility policy the facility failed to ensure a sanitary kitchen. This had the potential to affect all 43 of 43 residents who resided in the facility and received meals. Findings include: Observation on 05/12/25 at 8:05 A.M. of the soap dispenser with Dietary Manager #360 and Dietary Aide #306 revealed it was located above the hand washing station and it did not have soap in it. Dietary Aide #306 stated she would let housekeeping know the soap dispenser needed refilled. Observation on 05/12/25 at 8:07 A.M. of the facility kitchen revealed the floor had dried food bits and multiple dried, dark brown and clear, sticky fluid spills. Observation of metal counters, metal meal carts, metal shelves, doors and sides to the freezer, cooler, and oven revealed they were covered with whitish colored drip marks and what appeared to be dried food and liquid smudges. All the surfaces appeared grubby. Interview on 05/12/25 at 8:07 A.M. of Dietary Aide (DA) #306 and Dietary Manager (DM) #360 confirmed the floor had dried food bits 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility policy the facility failed to ensure Resident #23's open area to the right inner heel was identified and treated timely and failed to ensure weekly skin assessments were completed as ordered. This affected one resident (Resident #23) out of three residents reviewed for wounds. The facility census was 43. Findings include: Review of Resident #23 medical record revealed an admission date of 04/19/22 and diagnoses included anoxic brain damage, benign intracranial hypertension, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Review of Resident #23's physician orders dated 03/15/24 revealed weekly C1 Health Documentation to be completed one time a day, every Friday for routine care. Review of Resident #23's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had severe cognitive impairment. Resident #23 had no impairment of the upper extremities and impairment on both sides…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-19 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide 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 observation, interview, record review and review of facility policy the facility failed to ensure Resident #8 had comprehensive assessments of her dialysis access site post dialysis treatments. This affected one resident (Resident #8) of one resident reviewed for dialysis.Findings include:Review of Resident #8's medical record revealed an admission date of 02/06/25 and diagnoses included type two diabetes mellitus with diabetic neuropathy, paroxysmal atrial fibrillation, supraventicular tachycardia, and dependence on renal dialysis.Review of Resident #8's Dialysis Communication Forms dated 02/28/25 through 05/09/25 did not reveal evidence of immediate monitoring and documentation of the status of the Resident #8's access site upon return from the dialysis treatment to observe for bleeding or other complications. Review of Resident #8's care plan dated 02/13/25 included Resident #8 had renal failure related to ESRD (End Stage Renal Disease) with hemodialysis. Resident #8 would be kept comfortable in 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-19 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #4 was free from significant medication error. This affected one resident (Resident #4) of one resident reviewed for significant medication administration. The facility census was 43. Findings include: Review of Resident #4's medical record revealed an admission date of 01/09/25 with diagnoses including paroxysmal atrial fibrillation, pneumonia and chronic diastolic (congestive) heart failure. Review of the physician's orders revealed the resident had an order for Flecainide Acetate 50 milligrams twice a day. Flecainide acetate, sold under the brand name Tambocor is an antiarrhythmic drug used to treat certain types of abnormal heart rhythms. Review of Resident #4's care plan dated 01/12/25 included Resident #4 was at risk for decreased cardiac output and abnormal lab values related to congestive heart failure (CHF), shortness of breath, myocardial infarction, history of vascular bypass and other diagnoses. The goal…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure appropriate infection control practices were implemented during Resident #10's medication administration and Resident #23's incontinence care. This affected one resident (Resident #10) of five residents reviewed for medication administration and one resident (Resident #23) of one resident reviewed for incontinence care. Findings include: 1. Review of Resident #10's medical record revealed an admission date of organ-limited amyloidosis, vascular dementia, and acute kidney failure. Observation on 05/14/25 at 8:02 A.M. of Licensed Practical Nurse (LPN) #339 revealed she prepared Resident #10's medications, placed them in a small plastic cup, and walked into his room to administer the medications to him. Resident #10 was sitting on the edge of his bed, LPN #339 handed him the plastic cup and a cup of water and as Resident #10 was putting the pills in his mouth he dropped two of the pills on the floor. LPN…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-17 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, and staff interview, the facility failed to ensure care plans were updated to include new interventions for falls. This affected two (Residents #1 and #29) of three residents reviewed for falls. The facility census was 41 residents. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 10/24/24 with diagnoses including kidney failure, congestive heart failure (CHF), insomnia, muscle weakness and history of stroke. Review of the care plan for Resident #1 dated 10/26/24 revealed the resident was at risk for falls due to an unstable health condition. Interventions included assistance with all transfers and mobility, bed in a low position, call light within reach, and commonly used articles within reach. Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 11/01/24 revealed the resident was moderately cognitively impaired and required setup help for eating, and substantial or maximum assistance for oral hygiene, toileting and personal hygiene. Review of the nurses' note for Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure fall prevention interventions were implemented. This affected two (Residents #1 and #29) of three reviewed for falls. The facility census was 41 residents. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 10/24/24 with diagnoses including kidney failure, congestive heart failure (CHF), insomnia, muscle weakness and history of stroke. Review of the care plan for Resident #1 dated 10/26/24 revealed the resident was at risk for falls due to an unstable health condition. Interventions included assistance with all transfers and mobility, bed in a low position, call light within reach, and commonly used articles within reach. Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 11/01/24 revealed the resident was moderately cognitively impaired and required setup help for eating, and substantial or maximum assistance for oral hygiene, toileting and personal hygiene. Review of the nurses' note for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure oxygen tubing was changed as ordered. This affected one (Resident #1) of three residents reviewed for oxygen administration. The facility identified three (Residents #1, #7 and #25) who received oxygen. The facility census was 41 residents. Findings include: Review of the medical record for Resident #1 revealed an admission date of 10/24/24 with diagnoses including kidney failure, congestive heart failure (CHF), and history of stroke. Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 11/01/24 revealed the resident was moderately cognitively impaired and required setup help for eating, and substantial or maximum assistance for oral hygiene, toileting and personal hygiene. Review of the care plan for Resident #1 dated 10/26/24 revealed the resident had an ineffective breathing patterns as a result of shortness of breath. Interventions included administering medications and respiratory treatments as ordered, administering oxygen per…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-14 · tag F0607 — failed to have anti-abuse policies — widespread
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of the facility self-reported incident (SRI) tracking number (#)253244 and facility investigation, review of staffing schedules and punch detailed report and review of the facility abuse policy, the facility failed to enforce their abuse policy including reporting an allegation of abuse promptly, immediately investigating the allegation of staff-to-resident abuse and ensuring the alleged perpetrator did not continue providing direct care to all residents after the alleged allegation was made on 10/04/24. This affected one resident (#28) and placed a potential risk of abuse for all 40 residents residing in the facility. Findings included: Review of the medical record for Resident #28 revealed an admission date of 08/22/24 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, and spinal stenosis. There was no documentation in the nursing notes from 10/04/24 to 10/23/24 regarding any allegation of staff-to-resident abuse. Review of the care plan…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · F2024-11-14 · tag F0610 — failed to investigate and act on abuse reports — widespread
    Respond 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 record review, interview, review of the facility self-report incident (SRI) tracking number (#)253244 and investigation, staffing schedules and punch detailed report, and review of the facility abuse policy, the facility failed to immediately investigate and implement protective measures upon receiving an allegation of staff-to-resident abuse to prevent further abuse including not allowing the alleged perpetrator to continue to provide direct care from 10/04/24 to 10/23/24 while a thorough investigation was completed. This affected one resident (#28) and had the potential to affect all 40 residents residing in the facility. Findings include: Review of the medical record for Resident #28 revealed an admission date of 08/22/24 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, and spinal stenosis. There was no documentation in the nursing notes from 10/04/24 to 10/23/24 regarding any allegation of staff-to-resident abuse. Review of the care plan dated 08/30/24 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-14 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review and review of facility policy, the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) committee that met at least quarterly consisted of the required members, including the medical director or his/her designee. This had the potential to affect all 40 residents residing in the facility. Finding include: Review of the QAPI sign-in sheets from 10/20/23 to 08/21/24 revealed a QAPI meeting was held on 03/01/24, and Medical Director #660 attended the meeting. A QAPI sign-in sheet revealed a meeting was held on 06/27/24, and Medical Director #660 or designee had not attended. A QAPI meeting sign-in sheet revealed a meeting was held on 08/21/24, and Nurse Practitioner #661 attended the meeting as the medical director's designee. There was no evidence from 03/02/24 to 08/21/24 (over five months) that the facility had a QAPI meeting that the medical director and/or his designee attended. Interview on 11/13/24 at 9:00 A.M. with the Administrator verified she had no documented evidence from 03/02/24 to 08/21/24 (over five months)…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-14 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 observation, interview, record review and review of the facility policy, the facility did not notify the physician and/or designee regarding Resident #13's change in condition. This affected one resident (#13) out of six residents reviewed for change in condition. The facility census was 40. Findings include: Review of the medical record for Resident #13 revealed an admission date of 10/24/24 with diagnoses including chronic obstructive pulmonary disease (COPD), hypertension, congestive heart failure (CHF), and oxygen dependence. Review of the blood pressures dated from 10/24/24 to 11/07/24 revealed Resident #13's blood pressures included: 10/25/24 it was 130/76, 10/26/24 it was 138/78, 10/27/24 it was 134/76, 10/29/24 it was 106/54, 11/05/24 it was 110/76, and 11/06/24 it was 134/58. There was no documented evidence since admission, 10/24/24, that Resident #13's systolic blood pressure had been below 100. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-14 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of the facility self-report incident (SRI) tracking number (#)253244 and investigation, and review of the facility abuse policy, the facility failed to promptly report an allegation of staff-to-resident sexual abuse to the Ohio Department of Health (ODH), local police department, and physician from 10/04/24 until 10/23/24. This affected one resident (#28) out of six residents reviewed for abuse. The facility census was 40. Findings include: Review of the medical record for Resident #28 revealed an admission date of 08/22/24 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, and spinal stenosis. There was no documentation in the nursing notes from 10/04/24 to 10/23/24 regarding any allegation of staff-to-resident abuse. Review of the care plan dated 08/30/24 revealed Resident #28 had a self-care performance deficit related to fatigue, COPD, and weakness. Interventions included extensive assistance with toileting needs, monitoring for fatigue,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 call lights were within reach. This affected two residents (#33 and #36) out of six residents reviewed for call lights. This had the potential to affect 38 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #24, #25, #26, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, and #40) identified by the facility as capable of utilizing their call light to ring for assistance. The facility census was 40. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 04/09/21 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, and paranoid schizophrenia. Review of the care plan dated 03/13/24 revealed Resident #36 was at risk for falls due to impaired mobility, poor safety awareness, and unstable health condition. Interventions included maintaining her bed in the lowest position and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure oxygen was being administered according to physician orders and failed to ensure there was appropriate signage indicating oxygen was in use. This affected one resident (#13) out of two residents reviewed for oxygen use. This had the potential to affect six additional residents (#15, #20, #21, #24, #28, and #38) identified by the facility with an order for oxygen. The facility census was 40. Findings include: Review of the medical record for Resident #13 revealed an admission date of 10/24/24 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and dependence of oxygen. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had impaired cognition and received oxygen therapy. Review of the November 2024 physician orders revealed Resident #13 had a current order for three liters per minute of continuous oxygen…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, facility policy review, and review of the memorandum from the Department of Health & Human Services, the facility failed to ensure proper infection control measures were implemented at all times. The facility failed to initiate and use enhanced barrier precautions (EBP) for Resident #13. This affected one resident (#13) of one resident observed for EBP and had the potential to affect 11 residents (#1, #7, #11, #12, #13, #18, #20, #21, #24, #26, and #38) identified by the facility that were to be on EBP. The facility failed to ensure staff did not carry medications against their chest/body potentially causing infection control cross contamination affecting one resident (#13) of three residents reviewed for medication administration. The facility failed to cleanse the blood pressure cuff/monitor between resident use which affected one resident (#13) out of two residents reviewed for monitoring of blood pressure. The facility failed to ensure Resident #35's bed pan…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-07-20 · tag F0698 — failed to provide proper dialysis care — widespread
    Provide 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 record review and interview, the facility failed to ensure dialysis residents were monitored before and after dialysis treatments. The facility also failed to ensure resident dialysis catheters were assessed as ordered by the physician. This affected three (Resident's #12, #22, and #140) of three residents receiving dialysis. The facility census was 40. Findings include: 1. Review of the medical record revealed Resident #12 was admitted on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis. There were no dialysis assessments performed for Resident #12 before going to dialysis or after returning. Review of the physician's order dated 02/01/22 revealed Resident #12 had dialysis on Tuesdays, Thursdays, and Saturdays. Resident #12 also had a physician's order dated 01/05/22 for staff to monitor the left inter-jugular dialysis site every shift for signs of infection and to ensure that ports are clamped; document abnormal findings; report to dialysis center and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-20 · tag F0641 — pattern
    Ensure 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 4. Review of the medical record for Resident #18 revealed an admission date of 08/18/2020 with diagnoses including dementia with behavioral disturbance, schizoaffective disorder, delusional disorder, and depression. Review of the physician's order dated 10/01/21 revealed Resident #18 had an advance directive including palliative care program for chronic kidney disease. There were no physician's orders for hospice services. Review of the quarterly MDS 3.0 assessments dated 01/18/22 and 04/18/22 and the significant change MDS 3.0 assessment dated [DATE] revealed hospice services had been documented for Resident #18. Interview on 07/11/22 at 12:44 P.M. with Resident #18's daughter revealed Resident #18 had never received hospice services while in the facility. She verified Resident #18 received palliative care. Interview on 07/11/22 at 1:29 P.M. with LPN #512, who was also the MDS nurse, revealed she had documented hospice services for Resident #18. LPN #512 verified Resident #18 was not receiving hospice services…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and policy review the facility failed to ensure medications were administered as ordered. This affected three (Resident's #1, #20 and #22) of 11 residents reviewed for medications being administered as ordered. The facility census was 40. Findings include: 1. Review of the medial record for Resident #1 revealed an admission date of 04/04/19 with diagnoses including diabetes mellitus, dementia, human immunodeficiency virus (HIV), and chronic kidney disease. Review of the physician's orders dated 06/03/22 for Resident #1 revealed he had an order for Insulin Aspart Solution 100 units/milliliters (mL.), inject seven units subcutaneously with meals related for hyperglycemia and Insulin Aspart Solution 100 units/mL., sliding scale with meals (insulin amount given depending on blood sugar readings). Review of the Medication Administration Record (MAR) for June 2022 for Resident #1 revealed nursing staff did not administer Insulin Aspart Solution seven units with meals on 06/14/22, 06/15/22 and 06/24/22 at 5:00 P.M. The MAR also revealed nursing staff did…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to ensure pressure relieving interventions were implemented and pressure ulcer treatments were performed for Resident #35. This affected one (Resident #35) of one resident reviewed for pressure ulcers. The facility census was 40. Findings include: Review of the medical record revealed Resident #35 was admitted on [DATE] with diagnoses including dementia, lack of coordination, and hypertension. Review of the care plan dated 03/12/20 for Resident #35 revealed she had the potential for alteration in skin integrity related to incontinence, depression, need for personal assistance, and obesity. Interventions included to administer treatments as ordered, therapeutic specialty mattress to bed and monitor for functioning, and to turn and reposition as needed. Review of the physician's orders for Resident #35 revealed orders for skin prevention included a low air loss pressure mattress to the bed, check function every shift dated 05/12/20 and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of the facility policy on falls, the facility failed to ensure new fall prevention interventions were implemented after Resident #18 experienced falls. This affected one (Resident #18) of one resident reviewed for falls. The census was 40. Findings include: Review of the medical record for Resident #18 revealed an admission date of 08/18/20 with diagnoses including dementia with behavioral disturbance, schizoaffective disorder, delusional disorder, depression, muscle weakness, and difficulty in walking. Review of the fall investigations revealed Resident #18 experienced falls on 04/16/22, 05/21/22, and 07/01/22. Further review of the fall investigations revealed no new fall prevention interventions were implemented after Resident #18 experienced falls. Review of the falls care plan revised 07/12/22 revealed no new fall prevention interventions were implemented on or around 04/16/22, 05/21/22, and 07/01/22. Interview on 07/14/22 at 12:46 P.M. with the Director of Nursing (DON) verified no new interventions were implemented after Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-20 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview and policy review, the facility failed to ensure scheduled pain medications were administered to Resident #22 as ordered by the physician. The facility also failed to ensure pain assessments were performed as ordered by the physician for Resident #22. This affected one (Resident #22) of one resident assessed for pain management. The facility census was 40. Findings include: Review of the medial record for Resident #22 revealed an admission date of 10/21/21 with diagnoses including diabetes mellitus, chronic kidney disease, and osteoarthritis. Review of the care plan dated 11/03/21 for Resident #22 revealed she was at risk for pain discomfort related to osteoarthritis, cancer to her head/scalp area, depression, and diabetic neuropathy (weakness, numbness, and pain from nerve damage). Interventions included to assess for pain and to administer pain medications per the physician's order. Review of the physician's order dated 01/27/22 revealed nursing staff were to monitor for pain every shift. Resident #22 also had a physician's order dated 06/07/22…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-20 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure Resident #20 was free of significant medication errors. This affected one (Resident #20) of one resident reviewed for significant medication errors. The facility census was 40. Findings include: Review of the medical record revealed Resident #20 was admitted on [DATE] with diagnoses including dementia, schizophrenia, and anxiety. Review of the handwritten physician medication order dated 06/23/22 revealed Resident #20 was ordered Lexapro 10 milligrams (mg) daily for seven days and then increase Lexapro to 20 mg daily. Review of the Medication Administration Record (MAR) for June 2022 revealed Resident #20 had an order for Lexapro 10 mg one time a day for antidepressant for seven days then increase to 20 mg daily dated 06/24/22. Review of the MAR for July 2022 revealed Resident #20 was administered Lexapro 10 mg on 07/01/22, 07/02/22, 07/04/22 and 07/05/22 at 4:00 P.M. Lexapro 10 mg was discontinued on 07/06/22. Resident #20 had another 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of the facility's administration procedures for all medications, the facility failed to ensure medications were dated when opened and disposed of when expired or discontinued. This affected two (Resident's #1 and #20) of two residents whose insulins were stored in the medication cart. The facility census was 40. Findings include: 1. Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses including diabetes mellitus and dementia. Review of the physician's orders revealed Resident #1 had an order dated [DATE] for Insulin Aspart Solution (medication for diabetes), inject seven units subcutaneously with meals. He also had an order dated [DATE] for Insulin Aspart Solution for sliding scale, which would provide a dose depending on the resident's blood sugar. Resident #1's blood sugars were noted to range from 123 to 435 in [DATE]. Resident #1's blood sugars were noted to be between 68 to 538 in [DATE]. Observation on [DATE] at 12:43 P.M.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-05-16 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure medications in the [NAME] wing cart were secured under lock when the nurse was not in attendance. This had the potential to affect 17 residents (Resident #1, #4, #5, #6, #9, #13, #14, #15, #16, #18, #22, #24, #26, #35, #36, #187 and #189) on the [NAME] hall who received medications administered by the nursing staff. The facility census was 40. Findings Include: Observation on 05/15/19 at 4:30 P.M. in the [NAME] hallway revealed an unlocked medication cart stationed to the east of room [ROOM NUMBER]. No nurse was observed in the hallway or looking into the hallway. On 05/15/19 at 4:33 P.M. Licensed Practical Nurse #100 emerged from room [ROOM NUMBER] which was west of room [ROOM NUMBER], and past a large metal box fixed on the wall which extended approximately eight inches from the wall and approximately thirty three inches wide across the wall, partially blocking the view between the two rooms when standing at the doorway or in 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2019-05-16 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview the facility failed to ensure the most recent State survey results were readily accessible to its residents, staff and the general public. This had the potential to affect all 40 residents residing in the facility. Findings Include: Review of the facility publicly accessible survey results binder on 05/15/19 at 9:28 A.M. revealed the last noted survey results in the book were from a complaint survey dated 10/03/18. The Ohio Department of Health conducted complaint surveys at the facility on 03/07/19 and 03/12/19, the results of these surveys were not readily available in the survey book at the time of discovery. Regional Nurse Consultant #99 verified the lack of results in an interview on 05/15/19 at 9:32 A.M.

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • No harm found · C2019-05-16 · tag F0839 — widespread
    Employ staff that are licensed, certified, or registered in accordance with state laws.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to properly verify the nursing license of Licensed Practical Nurse (LPN) #100 prior to the employee working in the facility. This affected one LPN (LPN #100) of four LPNs whose personnel files were reviewed and had the potential to affect all 40 residents residing in the facility. Findings include: On 05/16/19 review of the personnel file for LPN #100 revealed an application date of 11/02/18 and hire date of 11/14/18. However, various facility orientation papers such as handwashing and gait belt policies were signed on 11/13/18. The file contained a license for a nurse with the same first and last name, but whom had been licensed as a nurse beginning in 1964. The page was dated 11/19/18. Additional records in the employee's file indicated a birth year in 1979, fifteen years after the licensure date. Interview on 05/16/19 at 12:15 P.M. with Human Resources Employee (HR) #105 confirmed the license in the file did not belong to LPN #100 as she had a different middle name and her birth year was listed as 1979. HR #105 stated 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.

    Administration Deficiencies · Deficient, Provider has plan of correction
  • No harm found · B2019-05-16 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview the facility failed to ensure Notices of Medicare Non-Coverage issued to residents contained all of the required information. This affected three residents (Resident #138, #139 and #140) of three residents reviewed for beneficiary notices. Findings Include: 1. Review of Resident #138's Notice of Medicare non coverage (NOMNC) form for services ending 12/13/18 and signed 12/07/18 revealed the notice contained no specific information about what services would be discontinued. 2. Review of Resident #139's Notice of Medicare non coverage (NOMNC) form for services ending 03/20/19 and signed 03/13/19 revealed the notice contained no specific information about what services would be discontinued. 3. Review of Resident #140's notice of Medicare non coverage (NOMNC) form for services ending 02/13/19 and signed 02/13/19 revealed the notice contained no specific information about what services would be discontinued. Social Service Designee #348 verified the notices for Resident #138, #139 and #140 lacked specific information about what services were…

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

    Resident Rights Deficiencies · Deficient, Provider has plan of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to 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 →

RatingThis homeChain avg
Overall 3 of 53.5-0.5 vs chain
Health inspection 3 of 52.7+0.3 vs chain
Staffing 1 of 52.2-1.2 vs chain
Quality measures 5 of 54.9≈ 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 / managerTypeRoleShareSince
OH 10 HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/06/2022
CC OH10 OPCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/06/2022
CHAVOS221 HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/06/2022
CHAVOS221 IRRV TROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/06/2022
LIONSVIEW OPCO NR LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/06/2022
LIONSVIEW SC LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/06/2022
LIVING26 HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/06/2022
LIVING26 IRRV TROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/06/2022
SAPPHIRE143 HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/06/2022
SAPPHIRE143 IRRV TROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/06/2022
STUMP, BARRYIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 05/14/1998
SHARVIT, ELIAVIndividualCORPORATE OFFICERsince 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.

$3.3M
Net patient revenuemost recent cost report
-12.1%
Operating marginrevenue minus expenses
$470K
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 32%Medicare 5%Other / private 64%

This home reported $470K paid to related parties — landlords or management companies under common ownership — equal to about 13% 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

$322per resident / day
operating cost
$9,801per month
≈ monthly operating cost
$288per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.

Typical monthly cost in Ohio
$9,186/mo
Nursing home (semi-private)
$10,389/mo
Nursing home (private)
$6,103/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365006. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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