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Crystal Care Of Coal Grove

813 1/2 Marion Pike, Coal Grove, OH 45638 · For profit - Corporation · 57 certified beds · (740) 532-0449 Medicare & Medicaid certified

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Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$159,708 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $159,708 in federal fines (most recent 2024-03-04)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (1/5)

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

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

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
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1920 S 9th St · (740) 532-0220 · Call to confirm hours
Pharmacy
1848 Campbell Dr · (740) 533-9215 · Call to confirm hours
Grocery
1113 Ironton Hills Drive
Park
1701 S 7th St · Typically dawn to dusk
Place of worship
2201 S 8th St

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 1 to 3 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 rating3★
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 increased8.4%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight7.4%6.2%5.4%worse
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 symptoms15.1%30.1%6.5%better 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 injury2.0%3.2%3.3%better
Long-stay residents whose ability to walk worsened4.6%6.1%16.1%better than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication54.8%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine96.5%94.5%95.3%typical
Long-stay residents with pressure ulcers2.1%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control16.4%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.3%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Long-stay hospitalizations per 1,000 resident days1.091.731.67better
Long-stay outpatient ER visits per 1,000 resident days1.181.801.80better

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.

12.0%U.S. median 10.7%
Went back to hospital
0.30U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a 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 SNF12.0%CMS range 8.5–18.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.031.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.44
RN hours/ resident / day
0.85
LPN hours/ resident / day
1.87
Aide hours/ resident / day
3.16
Total nurse hours/ resident / day
0.24
RN hoursweekends
48.8%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 57 beds and averages 50.6 residents a day — about 89% occupied, or roughly 6 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 3.16 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.87 hrs/resident/day on weekends vs 3.27 on weekdays — 12% thinner on weekends. RN hours go from 0.52 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2025-09-11)
9
at the previous standard inspection (2023-10-19)

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-03-04 · 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 closed medical record review, review of the hospital records, review of laboratory test requisitions, review of the facility's laboratory contract, staff interviews, and review of the facility policy, the facility failed to ensure timely and appropriate care and services were provided for Resident #60 following a change in condition. This resulted in Immediate Jeopardy and the potential for serious life-threatening injuries, negative health outcome and/or death on [DATE] at 10:29 A.M. when Resident #60 experienced a decline in condition. Nurse Practitioner (NP) #500 was notified of Resident #60's decline and provided new orders to obtain STAT (urgent) laboratory tests. The ordered laboratory tests were never obtained, and neither the physician nor the NP were notified of the laboratory tests not being obtained. On [DATE] at 8:40 A.M., Resident #60 further declined with pale, clammy skin and diminished breath sounds and the facility did not notify the physician nor the NP of Resident #60's decline 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-11 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure comprehensive care plans to address Post Traumatic Stress Disorder (PTSD) and suicidal ideations were initiated. This affected two Residents (#3 and #4) of 18 resident care plans reviewed. The facility census was 53. Findings include:1.Review of the medical record for Resident #3 revealed an admission date of 02/11/25 and a readmission date of 07/25/25 with diagnoses including Post Traumatic Stress Disorder (PTSD), insomnia, anxiety, depression, diabetes mellitus type two and bilateral above the knee amputations. Review of the five day Medicare minimum data set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact with no behaviors. Resident #3 needed assistance from the staff to complete activities of daily living. Resident #3 had diagnoses of PTSD, anxiety and depression. Review of the plan of care for Resident #3 revealed no plan of care addressing the PTSD cause, resident triggers, resident reaction behaviors and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-11 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review and staff interview the facility failed to ensure there were parameters in place for administration of as needed pain medications and non-pharmacological interventions. This affected one resident (#5) of four residents reviewed for pain management. The facility census was 53.Findings include:Review of the medical record for Resident #5 revealed an admission date of 07/25/25 with diagnoses including chronic kidney disease stage three, unspecified psychosis, rheumatoid arthritis, diabetes mellitus and malignant nodule of the lung. Review of the Medication Administration Record (MAR) dated 08/25 and 09/25 revealed Resident #5 received Tylenol 650 milligrams (mg) by mouth every eight hours as needed for pain, Tramadol 50mg by mouth every six hours as needed for pain and no nonpharmacological interventions were ordered. Additionally, no pain level parameters noted of when to administer each medication. Review of the significant change in status Minimum Data Set (MDS) dated [DATE]…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-11 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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, resident and staff interviews, and review of facility policy, the facility failed to provide an adequate plan of care for post-traumatic stress disorder and ensure staff were knowledgeable in the plan of care. This affected one (Resident #20) of three residents reviewed for mood and behavior. The facility census was 53.Findings include:1. Review of the medical record for Resident #20 revealed an admission date of 03/02/25. Diagnoses included PTSD, anxiety disorder, and depression.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 was cognitively intact and was able to make her needs known.Review of the trauma evaluation dated 03/02/25 revealed Resident #20 had experienced emotional abuse from earlier in her life with triggers of being in large crowds. Symptoms due to her PTSD included difficulty sleeping, fear, severe anxiety, and feelings of guilt or shame. Triggers included large groups of people.Review of the care plan dated 05/02/24 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-11 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, staff interview and review of facility policy the facility failed to implement pharmacy recommendations. This affected two Residents (#5 and #42) of five residents reviewed for unnecessary medications. The facility census was 53. Findings include: 1.Review of the medical record for Resident #5 revealed an admission date of 07/25/25 with diagnoses including chronic kidney disease stage three, unspecified psychosis, rheumatoid arthritis, diabetes mellitus, delusional disorder, schizoaffective disorder, major depressive disorder and malignant nodule of the lung. Review of the Medication Administration Record (MAR) dated 04/25, 05/25, 06/25, 07/25 and 08/25 revealed Resident #5 received Divalproex Sodium Sprinkles 125 milligrams (mg) by mouth, give four capsules to equal 500mg three times daily for schizoaffective disorder.Review of the pharmacy recommendations for Resident #5 dated 04/05/25 revealed Resident #5 was receiving the medication Depakote. The recommendation requested labs…

    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 before2025-09-11 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interview, the facility failed to ensure vital signs were monitored as ordered prior to the administration of medication. This affected one resident (#2) out of the five residents reviewed for unnecessary medications. The facility census was 53. Findings include:Record review for Resident #2 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hypertension, bipolar disorder, and depression.Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/18/25, revealed the resident was assessed to have intact cognition.Review of the active physicians order, dated 11/02/24, revealed the resident was to be administered 25 milligrams of Metoprolol (an anti-hypertensive medication) twice a day for hypertension and to hold medication for pulse below 60. Review of the Medication Administration Record (MAR) and recorded vital signs from 09/01/25 through 09/11/25 revealed no evidence the residents pulse was obtained prior to the administration…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, observation, resident interview, and review of facility policy, the facility failed to ensure dependent residents received assistance with incontinence care and eating. This affected three (Residents #23, #47, #53) of 37 facility-identified incontinent residents and affected one (Resident #53) of five facility-identified residents who required physical assistance with meal consumption. The facility census was 52. Findings include: Review of the lists provided by the facility revealed there were 37 residents (#1 #3, #4, #5, #8, #9, #10, #11, #15, #16, #17, #18, #19, #21, #22, #23, #27, #28, #30, #32, #34, #35, #36, #37, #38, #39, #41, #42, #44, #45, #46, #47, #49, #51, and #52) identified as being incontinent of bowel and/or bladder and five residents (#4, #47, #53, #44, and #49) who required physical assistance from staff for eating. 1. Review of the medical record for Resident #53 revealed an admission date of 01/30/24 with diagnoses including depression, hypertension, anxiety, and age-related cognitive decline. Review of the Minimum Data…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-26 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, observation, resident interview, and review of facility policy, the facility failed to ensure there were sufficient staff present to provide care and services to residents. This affected three (Residents #23, #47, #53) of 37 facility-identified incontinent residents and affected one (Resident #53) of five facility-identified residents who required physical assistance with meal consumption. The facility census was 52. Findings include: Review of the lists provided by the facility revealed there were 37 residents (#1 #3, #4, #5, #8, #9, #10, #11, #15, #16, #17, #18, #19, #21, #22, #23, #27, #28, #30, #32, #34, #35, #36, #37, #38, #39, #41, #42, #44, #45, #46, #47, #49, #51, and #52) identified as being incontinent of bowel and/or bladder and five residents (#4, #47, #53, #44, and #49) who required physical assistance from staff for eating. Observation on 03/25/24 at 8:25 A.M. revealed there were two licensed nurses and three State Tested Nursing Assistants (STNAs) present in the facility to provide care for 52 residents. Interview on 03/25/24…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-19 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility policy review the facility failed to ensure target behaviors were identified and appropriate indications for use of antipsychotic medications. This affected six residents (#16, #28, #30, #36, #38 and #43) of seven reviewed for unnecessary medications. The facility census was 41. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 12/21/18 with diagnoses including hypertension, psychosis and major depressive disorder. Review of the physician orders for October 2023 revealed Resident #16 was ordered clonazepam (antianxiety medications) 0.5 milligrams (mg) by mouth three times a day for unspecified psychosis, risperidone (antipsychotic medications) four mg by mouth two times daily for unspecified psychosis and citalopram hydrobromide (antidepressant medication) 40 mg by mouth daily for inappropriate sexual behaviors. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 was severely cognitively…

    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 · E2023-10-19 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the infection/antibiotic stewardship log, interview, and policy review the facility failed to ensure all prescribed antibiotics were appropriate. This had the potential to affect all 41 residents residing in the facility. Findings include: Review of the infection control log dated 01/2023 to 09/2023 revealed there was no evidence in February, March, April, May, June and September 2023 the facility identified the organism of the infection and ensured the antibiotic met the criteria for treatment. Further review of the log revealed in February 2023 there was six urinary tract infections (UTI), two gastrointestinal (GI), one skin, and three lower respiratory infections identified. All the infections were treated with antibiotics and did not meet the criteria for antibiotic treatment. Further review of the log revealed in March 2023 there was two upper respiratory infections (URI), two lower respiratory infection, two GI infections, three skin infections, and five UTI's identified. All the infections were treated with antibiotics and did not meet the criteria 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-19 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of the facility policy revealed the facility failed to ensure adequate monitoring, screening and offering of pneumonia vaccine. This affected four residents (#28, #29, #30 and #36) of five reviewed for immunizations. The facility census was 41. Findings include: Review of the medical record for Resident #28, #29, #30 and #36 revealed the residents did not receive the appropriate pneumonia vaccination based on the Centers of Disease Control and Prevention (CDC) guidelines. Interview on 10/19/23 at 3:40 P.M. with the Director of Nursing and the Assistant Director of Nursing confirmed Resident #28, #29 #30 and #36 did not receive the appropriate pneumonia vaccination as recommended by the CDC. Review of the facility policy titled Pneumococcal Vaccine, with no date, indicated prior to admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated, will be offered the vaccine series within thirty days of the admission to the facility unless medically contraindicated or the resident has…

    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
Show the remaining 14 citations
  • Potential for harm · Dcited before2023-10-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the comprehensive plan of care was developed and implemented based on the residents preferences and needs and the plan of care was not person centered. This affected three residents (#28, #29 and #32) of 12 residents reviewed for plan of care. The facility census was 41. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 03/12/22 with diagnoses including dementia with behavioral disturbances, type two diabetes mellitus, metabolic encephalopathy, major depressive disorder and anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 had severe cognitive impairment with inattention. Resident #28 required extensive assistance of one person for transfers and supervision with mobility due to unsteady balance and gait. Review of the activity assessment dated [DATE] for Resident #28 revealed Resident #28 preferred self initiated activities in her room such as…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-19 · 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 observations, interviews, and record reviews, the facility failed to ensure monitoring of a resident's skin after post surgical intervention. This affected one resident (#32) of the two residents reviewed for skin conditions during the annual survey. The facility census was 41. Findings include: Record review for Resident #32 revealed this resident was admitted to the facility on [DATE] and had diagnoses including acquired absence of the right leg below the knee, nicotine dependence, and viral hepatitis C. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/05/23, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require supervision for bed mobility, transfers, toileting, and eating. Review of the care plan, most recently revised on 05/10/23, revealed this resident was at risk for impaired skin integrity related to a left below the knee amputation and prosthetic leg left extremity…

    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 before2023-10-19 · 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 observations, interviews, record reviews, and review of facility policy, the facility failed to ensure adequate care and services were provided to identify residents at risk for elopement and prevent elopement. This affected two residents (#4 and #43) out of the five residents residents reviewed for accidents during the annual survey. The facility census was 41. Findings include: 1. Record review for Resident #4 revealed this resident was admitted to the facility on [DATE] and had diagnoses including anxiety disorder, schizophrenia, mood disorder, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/14/23, revealed this resident was rarely/never understood evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 99. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision for eating. This resident was assessed to use a wander/elopement alarm daily. Review…

    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 before2023-10-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review revealed the facility failed to implement dietary recommendations timely. This affected one resident (#29) of four residents reviewed for nutrition. The facility census was 41. Findings include: Review of the medical record for Resident #29 revealed an admission date of 07/01/21 with diagnoses including vascular dementia with behavioral disturbances, psychotic disorder with delusions, major depression, anxiety disorder, type two diabetes mellitus, and chronic obstructive pulmonary disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was severely cognitively impaired with inattention disorder, disorganized thinking and problems with appetite. Resident #29 required staff assistance with eating. Resident #29 weighed 159 pounds with no weight loss, or dental problems. Review of the physician orders for October 2023 revealed Resident #29 was on a regular diet, puree texture and thin liquids. Resident #29…

    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 before2023-10-19 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews, and review of facility policy, the facility failed to ensure pharmacy recommendations were reviewed and implemented timely. Additionally, the facility failed to ensure the policy for pharmacy recommendations addressed actions to be taken for urgent pharmacy recommendations. This affected three residents (#28, #38, and #43) of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 41. Findings include: 1. Record review for Resident #38 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia without behavioral disturbances, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/15/23, revealed this resident was assessed to be rarely/never understood evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 99. This resident was assessed to be dependent upon two staff members for transfers 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-19 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure adequate instructions and indications for the use of topical medications. This affected one resident (#43) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 41. Findings include: Record review for Resident #43 revealed this resident was admitted to the facility on [DATE] and had diagnoses including hypertension, abnormal glucose, anxiety disorder, insomnia, and dementia. Review of the admission Minimum Data Set (MDS) assessment, dated 08/24/23, revealed this resident had severely impaired cognition evidenced by a BIMS assessment score of 00. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the active physicians order, dated 08/18/23, revealed an order to apply Nystatin External Cream 100,000 units per gram topically to affected areas every eight hours as needed. The order did not contain…

    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 · D2021-12-07 · 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

    Based on record review, facility policy and procedure review and interview the facility failed provide necessary care and services, including dressing changes and antibiotic administration for Resident #41 who had three Stage IV pressure ulcers to promote wound healing. This affected one resident (#41) of two residents reviewed for pressure ulcers. Findings Include: Review of Resident #41's medical record revealed the resident had medical diagnoses including multiple sclerosis (MS), major depressive disorder, panic disorder, quadriplegia, Type II diabetes mellitus without complications, pressure ulcer of unspecified site (Stage IV), and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/12/21 revealed the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. The assessment revealed the resident had three Stage IV pressure ulcers that were present at the time of admission. Interventions listed included pressure reducing devices for her chair and bed, turning/repositioning program, nutrition or…

    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 before2021-12-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview the facility failed to ensure fall interventions were in place as care planned for Resident #16 who had a history of falls and was assessed to be at risk for falls. This affected one resident (#16) of one resident reviewed for falls. Findings Include: Review of the medical record for Resident #16 revealed an admission date of 04/17/21 with medical diagnoses including unspecified dementia with behavioral disturbance, generalized anxiety disorder, abnormalities of gait and mobility, muscle weakness and Alzheimer's Disease. Review of the plan of care, dated 04/19/21 revealed Resident #16 was at risk for falls. Interventions included bed in lowest position except when providing direct care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/21 revealed the resident had severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of three. The assessment revealed the resident required limited assistance from one staff with bed mobility, ambulation and transfers. The assessment revealed the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-12-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure Resident #1, who was identified as having had a significant weight loss, had documented evidence of substitutes being offered when the resident ate less than 50% of her meal as per her plan of care. This affected one resident (#1) of four residents reviewed for nutrition. Findings Include: A review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, schizophrenia, schizo-affective disorder, unspecified psychosis, major depressive disorder and a malignant carcinoid tumor of the bronchus and lung. A review of Resident #1's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/09/21 revealed the resident did not have any communication issues and was cognitively intact. No behaviors or rejection of care was noted. The resident required supervision with set up help for eating. Her height was 68 inches and her weight was 209 pounds. She was noted to have…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-12-07 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of pharmacy re-order slips, facility policy review and staff interview the facility failed to ensure medications were available from the contracted pharmacy to be administered to residents as ordered by the physician. This affected two residents (#30 and #31) of two residents reviewed for medication administration. Findings Include: 1. A review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including bipolar disorder and generalized anxiety disorder. A review of Resident #30's physician's orders revealed the resident was to receive Citalopram Hydrobromide (Celexa) 10 milligrams (mg) by mouth (po) every morning for bipolar disorder. The resident was also to receive Hydroxyzine Pamoate (Vistaril) 25 mg po twice daily for generalized anxiety disorder and Magnesium Oxide 250 mg by mouth every morning as a supplement. On 11/30/21 at 8:42 A.M., a medication administration observation was completed for Resident #30…

    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 before2021-12-07 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of pharmacy recommendations, facility policy and procedure review and staff interview the facility failed to implement pharmacy recommendations timely for Resident #3, Resident #23 and Resident #24. This affected three residents (#3, #23 and #24) of five residents reviewed for unnecessary medication use. Findings Include: 1. Review of the medical record for Resident #3 revealed the resident had medical diagnoses including Alzheimer's Disease, Wernicke's encephalopathy, pseudobulbar affect, dementia in other diseases classified elsewhere with behavioral disturbance, anxiety disorder, altered mental status, major depressive disorder, unspecified mood (affective) disorder and alcohol abuse with alcohol-induced psychotic disorder with hallucinations. Review of the plan of care, dated 11/04/17 for Resident #3 revealed the resident was at risk for adverse reactions related to dementia with behaviors and at risk for adverse effects related to anxiolytic drug use related to the diagnoses of anxiety and mood disorder. Interventions included pharmacy reviews 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-12-07 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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, review of the facility's contingency medication supply list, review of facility meal times, policy review and staff interview the facility failed to maintain a medication error rate of less than five (5) percent (%). The medication error rate was calculated to be 10% and included three medication errors of 30 medication administration opportunities. This affected one resident (#31) of two residents observed for medication administration. Findings Include: A review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including gastro-esophageal reflux disease (GERD) and adult onset diabetes mellitus. A review of Resident #31's physician's orders revealed Resident #31 was to receive Humalog insulin subcutaneously (SQ) before meals (AC) and at bedtime (HS) per sliding scale. The resident also had an order to receive Lantus insulin 60 units SQ twice daily for her diabetes mellitus and Carafate 1 gram (gm) by mouth AC and HS…

    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 · D2021-12-07 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's menu, meal ticket review and staff interview the facility failed to ensure a resident received the appropriate diet in the form that was required by the resident and ordered by the physician. This affected one (Resident #1) of four residents reviewed for nutrition. Findings include: A review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, history of a stroke and dysphagia. A review of Resident #1's speech therapy discharge summary for dates of service 06/18/21 through 07/06/21 revealed the resident was seen by speech therapy for dysphagia. Discharge recommendations included the use of a mechanical soft diet with chopped textures. She had previously been on a pureed diet but was thought to be safe for an upgrade in her diet as she was not showing any signs or symptoms of aspiration. A review of Resident #1's active physician's orders revealed the resident was ordered 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2021-12-07 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 the daily staffing posted information included hours worked for Registered Nurses (RN), Licensed Practical Nurses (LPN) and State Tested Nursing Assistants (STNA) and the number of RNs working. In addition, the staffing information sheets contained extraneous information that made the posting unclear and hard to understand. This had the potential to affect all 43 residents residing in the facility. Findings Include: Review of the Direct Care Staffing Sheets revealed from 11/16/21 to 11/30/21 there were 12 times when the number of Registered Nurses working only had a checkmark placed in the staffing column area instead of the actual number. The Direct Care Staffing Sheets did not show the actual number of hours worked for RNs, LPNs or STNAs for each date reviewed. The Direct Care Staffing Sheet also had eight employees names who were not RNs, LPNs or STNAs written on the bottom of the postings as providing direct and indirect care to all residents. On 12/02/21 at 12:43 P.M. interview with the Director of Nursing (DON)…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“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

$159,708 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $159,708 — penalty dated 2024-03-04
  • Medicare payment denial — starting 2024-03-29 for 18 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to HILLSTONE HEALTHCARE — 9 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 53.9-0.9 vs chain
Health inspection 3 of 53.3-0.3 vs chain
Staffing 1 of 51.8-0.8 vs chain
Quality measures 5 of 55.0≈ chain avg
The other 8 homes this chain runs (chain average 3.9★, 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 / managerTypeRoleSince
DETTY, PETERIndividualW-2 MANAGING EMPLOYEEsince 03/01/2016
RAMSEY, TARAIndividualW-2 MANAGING EMPLOYEEsince 02/16/2023
BERGSTEN, PAULIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2016
DAPORE, MATTHEWIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2016

CMS files one row per role, so the 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$4.0M
Net patient revenuemost recent cost report
-3.8%
Operating marginrevenue minus expenses
$308K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 5%Other / private 26%

This home reported $308K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$255per resident / day
operating cost
$7,759per month
≈ monthly operating cost
$246per 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 366202. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-11, 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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