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Briarwood Village

100 Don Desch Drive, Coldwater, OH 45828 · For profit - Corporation · 112 certified beds · (419) 678-2311 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Apr 2025Resident-funds citation (F0565)Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$17,345 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $17,345 in federal fines (most recent 2025-08-14)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (64%) runs well above the national median (45%)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
809 W Main St · (419) 678-2381 · Call to confirm hours
Pharmacy
404 W North St · (419) 678-3435 · Call to confirm hours
Grocery
810 E Main St · (419) 678-2056 · Call to confirm hours
Park
Vine St · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 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 rating1★
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 increased6.3%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight3.7%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.3%0.2%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.6%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms2.6%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 injury8.1%3.2%3.3%worse
Long-stay residents whose ability to walk worsened7.4%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication20.0%25.5%18.9%typical
Long-stay residents given the seasonal flu vaccine93.3%94.5%95.3%typical
Long-stay residents with pressure ulcers4.7%3.4%4.7%typical
Long-stay residents with worsening bladder/bowel control27.7%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.7%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication2.0%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine28.4%75.6%79.4%worse
Short-stay residents rehospitalized after admission27.9%24.9%22.6%worse
Short-stay residents with an outpatient ER visit15.3%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.211.731.67better
Long-stay outpatient ER visits per 1,000 resident days1.601.801.80better

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.

55.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 144 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.5%U.S. median 51.5%
Got home and stayed home
9.1%U.S. median 10.7%
Went back to hospital
67.2%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 67.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 61 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 SNF55.5%CMS range 48.4–62.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.1%CMS range 6.5–12.710.7%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 discharge67.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge65.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge49.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified84.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 4.3–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.111.02Oct 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

0.68
RN hours/ resident / day
0.59
LPN hours/ resident / day
2.11
Aide hours/ resident / day
3.37
Total nurse hours/ resident / day
0.47
RN hoursweekends
64.5%
Total nursing turnover
63.2%
RN turnover

How full it usually is: this home is certified for 112 beds and averages 95.1 residents a day — about 85% occupied, or roughly 17 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 3.37 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 2.99 hrs/resident/day on weekends vs 3.53 on weekdays — 15% thinner on weekends. RN hours go from 0.76 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

6
deficiencies at the latest standard inspection (2024-08-08)
10
at the previous standard inspection (2022-10-25)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

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.

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-08-14 · 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, medical record review, staff interview, review of facility investigation, physician interview, review of bed user service manual, and policy review, the facility failed to ensure Resident #01 was provided adequate supervision during the provision of activities of daily living. Resident #01 was cognitively impaired, and dependent on staff for transfer and bed mobility with bilateral lower extremity contractures. This resulted in Immediate Jeopardy, actual harm and death beginning on [DATE] at 10:11 A.M. when two Certified Nurse Aides (CNA) directed attention away from Resident #01, who was lying in bed on her left side with the bed elevated. Resident #01 rolled from the elevated bed and fell to the floor, sustaining a laceration to the scalp requiring six staples, acute odontoid process fracture (second cervical vertebra [C2] in the neck) and closed displaced fracture of first cervical vertebra (C1 in the neck). On [DATE] Resident #01 expired as a result of the injuries sustained at the time…

    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 · D2025-09-15 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of resident council meeting minutes and staff interview, the facility failed to respond to resident concerns addressed in resident council meetings. This affected two residents (#242 and #249) of four residents reviewed for Resident Council. The facility census was 95.1.Review of the Resident Council Meeting Minutes (RCMM) dated 07/01/25 revealed concerns with the dietary department. Further review revealed there was no evidence of action taken to address residents' concerns. Interview on 09/15/25 at 12:12 P.M. with the Administrator verified she was unable to locate evidence of staff action taken in response to concerns brought up by residents during the August 2025 Resident Council Meeting (RCM). 2. Review of the RCMM for 08/05/25 revealed residents' voiced concerns of receiving their medications late on the weekends due to nurse helping the aides. Nurses were sitting medications at bed side and leaving. Also, residents voiced concerns of sheets not fitting bigger sized beds. 2. Review of 08/05/25 RCMM revealed on the weekends residents were getting their…

    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 · D2025-09-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interviews, and staff interviews, the facility failed to complete residents' showers as scheduled. This affected three residents (#249, #242, and #212) of three residents reviewed for showers. The census was 951.Review of the medical record for Resident #249 revealed an admission date of 03/06/23 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD).Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #249 a Brief Interview for Mental Status (BIMS) score of eight, indicating impaired cognition. He required set-up or clean up assistance for Activities of Daily Living (ADLs).Review of Resident #249's shower sheets for the past 14 days revealed the following: 09/02/25 not applicable, 09/05/25 no shower given, 09/25/25 shower given, and 09/12/25 not applicable. Further review revealed Resident #249's scheduled shower days were Tuesdays and Fridays. Interview on 09/15/25 at 10:00 A.M. with Resident #249 revealed the resident needs help with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-15 · 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, medical review, staff interview, and review of a facility policy, the facility failed to follow infection control procedures for a resident positive with COVID-19. This affected one (Resident #249) of one resident reviewed for COVID-19 precautions. The facility census was 62.Review of the medical record for Resident #249 revealed an admission date of 03/06/23. The resident was admitted with diagnosis of COVID-19.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of eight, indicating moderately impaired cognition. This resident was assessed to require set or clean-up assistance for bathing, dressing, and toileting.Review of the progress note dated 09/09/25 revealed Resident #249 tested positive for COVID-19 and was placed in droplet isolation for ten days. Observation on 09/15/25 at 10:00 A.M. Resident #249 and Resident #242 were talking by Resident #242's doorway. Resident #242 was standing just outside of Resident #249's door…

    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 before2025-04-07 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, local health department staff interview, and review of facility policy, the facility failed to report norovirus cases and multiple resident's gastrointestinal (GI) symptoms (nausea/vomiting/diarrhea) to the local health department. This had the potential to affect all 92 residents of the facility. The census was 92. Findings include: 1. Review of Resident #4's medical record revealed an admission date of 09/19/22. Diagnoses listed included chronic kidney disease, obstructive sleep apnea, hypothyroidism, and morbid obesity. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact. Review of progress notes revealed Resident #4 was not feeling well and was sent to the emergency room (ER) for evaluation on 02/25/25. Resident #4 returned to the facility on [DATE]. Review of hospital documentation revealed Resident #4 tested positive for norovirus on 02/25/25. 2. Review of Resident #107's medical record revealed an admission…

    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 · D2025-04-07 · 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 medical record review, staff interview, review of facility policy, and review of the Ohio Department of Health (ODH) Application Gateway, the facility failed to report an incident of resident-to-resident physical abuse to the state agency. This affected one (#19) of three residents reviewed for abuse. The census was 92. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 11/30/21. Diagnoses listed included Alzheimer's disease, psychotic disorder, hearing loss, and generalized anxiety disorder. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was rarely understood by staff. Review of progress notes revealed on 03/21/25 at 8:30 P.M. Resident #19 was walking with her walker and came to stop in front of of an empty recliner in the common area. A resident sitting in a nearby chair began yelling at Resident #19. A third resident came into the area and told Resident #19 to move. Resident #19 has confusion, and did not move. The 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-10-02 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, staffing record review, and staff interviews, the facility failed to employ a Director of Nursing (DON) full time at the facility. This had the potential to affect all 86 residents. Findings include: Interview on 09/30/24 at 7:17 A.M. at the time of entrance with the Administrator revealed there was no DON employed at the facility. A second interview with the Administrator on 10/01/24 at 10:11 A.M. revealed the facility had not had a DON or acting DON since 09/18/24. Record review of the staffing sheets from 09/23/24 through 09/29/24 revealed no DON had been scheduled.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-08-08 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on employee file review and interview the facility failed to ensure State Tested Nursing Assistant (STNAs) had 90 day evaluations and/or annual performance evaluations. This affected four of six employee files reviewed. This had the potential to affect all residents. The facility census was 99. Findings include: 1. Review of employee file for STNA #353 with hire date of 05/14/19 revealed no annual evaluation for July of 2023 or any for 2024. 2. Review of employee file for STNA #374 with hire date of 11/06/18 revealed no annual evaluation for 2020, 2021, and 2023. 3. Review of employee file for STNA #370 with hire date of 01/10/24 revealed no 90 day evaluation. 4. Review of employee file for STNA #331 with hire date of 10/05/23 revealed no 90 day evaluation. Interview on 08/08/24 at 11:04 A.M. with Human Resources (HR #508) verified the evaluations were not in the employee files for STNAs #353, #374, #370, and #331.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-08-08 · tag F0947 — failed to train nurse aides adequately — widespread
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on employee file review, interview, and policy review, the facility failed to ensure State Tested Nursing Assistants (STNAs) completed 12 hours of education. This affected two of three STNA files reviewed for annual training. This had the potential to affect all residents. The facility census was 99. Findings include: 1. Review of employee file for STNA #353 with hire date of 05/14/19 revealed no education training for 2023 or 2024. 2. Review of employee file for STNA #389 with hire date of 02/09/22 revealed no education training for 2023 or 2024. Interview on 08/08/24 at 11:02 A.M. with Executive Director (ED) verified the employees were not compliant with their education. ED stated the employees are scheduled to take courses. Review of policy titled, Inservice Education, dated 10/2003 revealed Nursing Assistants are required to have 12 hours of training per year calculated from their date of hire.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-08 · 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, observation, resident interview, staff interview, and the review of the facility policy, the facility failed to develop and initiate a care plan in regards to a corrective device for a resident. This affected one resident (#195) of three residents reviewed for range of motion. The facility census was 99. Findings include: Record review for Resident #195 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #195 included post surgical care for digestive tract, overactive bladder, sciatica, and pulmonary hypertension. Further review of Resident #195's list of diagnoses revealed there were no diagnosis relating to a fracture of the leg noted in the medical records. Review of Resident #195's care plans dated 07/26/24 revealed no focus for the plan of care for a walking cast. Review of Resident #195's physician orders revealed no orders for a walking cast. Observation and interview on 08/05/24 at 11:22 A.M. with Resident #195 revealed the resident was alert 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 · Dcited before2024-08-08 · 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 record review and interview, the facility failed to monitor bruises once observed. This affected one resident (#59) of one resident reviewed for bruising. The facility census was 99. Findings include: Review of medical record for Resident #59 revealed an admission date of 03/29/24 with diagnoses including but not limited to Parkinson's disease, dementia, anxiety, pain in right hip, and syncope and collapse. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment with no behaviors. Resident #59 required supervision/touching assistance for activities of daily living. Review of the care plan dated 07/10/24 revealed Resident #59 was at risk for bleeding/bruising related to platelet aggregated therapy. Interventions included medications as tolerated and monitor for signs and symptoms of bruising or bleeding every shift. Review of current physician orders for Resident #59 revealed clopidogrel (blood thinner) 75 milligrams (mg) daily and monitor for signs 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
Show the remaining 17 citations
  • Potential for harm · D2024-08-08 · 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, Medscape review, medical record review, interview, and policy review, the facility failed to ensure residents did not receive outdated insulin. This affected one (Resident #30) of two residents reviewed for insulin. The facility census was 99. Findings include: Review of the medical record for Resident #30 revealed an admission date of 10/07/21 with diagnoses including but not limited to type two diabetes with diabetic neuropathy, type two diabetes with diabetic cataract, type two diabetes with hypoglycemia without coma, long-term (current) use of insulin, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #30 received insulin seven out of seven days during the look back period. Review of current physician orders revealed insulin aspart solution 100 unit/ml inject per sliding scale: if 150-200 give 2 units; 201-250 give 4 units; 251-300 give 6…

    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 before2024-08-08 · 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, medical record review, staff interview, and policy review, the facility failed to ensure medications were not left at the bedside. This affected one (Resident #26) of one residents observed. The facility census was 99. Findings include: Review of the medical record of Resident #26 revealed an admission date of 01/04/23. Diagnoses included congestive heart failure, rheumatoid arthritis, diabetes mellitus type II, anxiety disorder, depression, and cerebral ischemia. Review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #26 was cognitively intact. Observation on 08/05/24 at 10:10 A.M. revealed a small plastic cup containing 18 pills/capsules sitting on the over bed table next to Resident #26. The medications included acetaminophen 325 milligrams (mg) 2 tablets, ascorbic acid 500 mg two tablets, cyanocobalamin 500 micrograms (mcg) tablet, isosorbide mononitrate extended release 30 mg capsule, multivitamin tablet, omeprazole 40 mg capsule, sitagliptin phosphate 50 mg…

    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 · Fcited before2022-10-25 · 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, staff interview, review of the kitchen daily cleaning schedule, and policy review, the facility failed ensure foods were labeled and dated, discard expired foods, and resident meals trays were covered during transport to resident rooms. In addition, the kitchen area and equipment was not maintained in a sanitary manner. This had the potential to affect all residents who resided in the facility and received food from the kitchens. The facility census was 73. Findings include: Observation on 10/17/22 at 9:20 A.M. of the facility kitchen and storage area revealed the following sanitation violations: 1. In the dry food storage one large bag of brown sugar next to a large plastic storage bin with brown sugar both open and undated. The large plastic storage container storing the brown sugar was sitting on a plastic food service tray with brown sugar laying on the surface. In the walk-in refrigerator, the following items were opened, unlabeled and undated, 1. Open package of cheddar cheese. 2. Open package of mozzarella cheese, 3. Open package of shredded lettuce, 4.…

    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 · Ecited before2022-10-25 · 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

    Based on observation, staff interview, and policy review, the facility failed to ensure medications were stored at proper temperatures. This affected 15 residents (#11, #56, #14, #42, #14, #48, #34, #26, #15, #13, #61, #07, #06, #37 and #274) and had the potential to affect all 59 residents on the A, B, C, and D halls. The facility identified three resident medication refrigerators. The facility census was 73. Findings include: 1. Interview and observation on 10/19/22 at 1:20 P.M. with Registered Nurse (RN) #245 of the A, B, C, and D hall refrigerator revealed the third shift charge nurse was responsible to check the refrigerator temperatures and log them daily. The log sheet on the refrigerator had temperatures on 10/03/22, 10/05/22, 10/17/22, 10/18/22, and 10/19/22 and each were documented within the 35 to 46 degree Fahrenheit parameters. The temperature during the observation the temperature during observation was 50 degrees. This was verified at the time of finding. 2. Interview and observation on 10/19/22 at 1:28 P.M. with RN #245 of the refrigerator in the infection…

    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 before2022-10-25 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and review of personnel files, the facility failed to provide newly hired State Tested Nurse Aides (STNA) with training on caring for residents with a diagnosis of dementia. This had the potential to affect 44 residents (#41, #51, #40, #328, #50, #27, #30, #48, #68, #277, #26, #60, #03, #07, #39, #69, #17, #56, #38, #12, #06, #19, #374, #62, #04, #28, #63, #70, #46, #08, #35, #37, #02, #29, #31, #15, #47, #36, #18, #67, #22, #124, #375, and #13) out of 44 residents diagnosed with dementia. The facility census was 73. Findings include: Review of the personnel file for STNA #231 revealed a hire date of 12/29/21. Further review revealed no documented training for residents with dementia. Review of the personnel file for STNA #236 revealed a hire date of 04/01/22. Further review revealed no documented training for residents with dementia. Interview on 10/20/22 at 1:31 P.M. with the Human Resources Director #248 verified the personnel files for STNA #231 and STNA #236 contained no verification they had received training on caring for residents with dementia.…

    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 · D2022-10-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure resident rooms remained clean. This affected two residents (#21 and #64) out of 73 residents' rooms observed. The facility census was 73. Findings include: 1. Review of the medical record of Resident #21 revealed an admission date of 11/12/10 and a readmission date of 12/08/20. Diagnoses included aphasia following a cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side, osteoarthritis, benign neoplasm of peripheral nerves and autonomic nervous system, disorders of brain, and cerebrovascular disease. Review of the annual minimum data assessment dated [DATE] revealed Resident #21 was cognitively intact and had 12 to 14 days of feeling down, depressed, or hopeless. She had trouble falling or staying asleep or sleeping too much two to six days, and felt tired or had little energy seven to 11 days. The total score was a six indicating a…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-25 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff and family interview, the facility failed to ensure a comprehensive skin assessment was completed on residents. This affected one resident (#46) out of 18 residents sampled. The facility census was 73. Findings include: Review of medical record for Resident #46 revealed admission date of 08/19/22. Diagnoses included dementia without behaviors, chronic obstructive pulmonary disease, depression, and congestive heart failure. The admission Minimum Data Set (MDS) dated [DATE] revealed he had intact cognition and required extensive two-person assistance for bed mobility, toilet use, one person for transfers and supervision for eating. No skin alterations documented. Review of the plan of care for potential/actual impairment to skin integrity related to fragile skin was created on 09/21/22. No other skin care plans were in place. Review of a progress note for Resident #46 dated 08/19/22 revealed a large brown protruding mole to the top of the scalp which measured…

    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 · D2022-10-25 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record of Resident #38 revealed an admission date of 11/11/15. Diagnoses included other speech disturbances, unspecified hydrocephalus, contusion of left knee sequela, unspecified constipation, other dysphagia, unspecified systolic (congestive) heart failure, paroxysmal atrial fibrillation, non-ST elevation myocardial infarction, and rhabdomyolysis. Review of the PAS (Pre-admission Screen) Review dated 04/11/13 revealed Resident #38 had no indications of serious mental illness nor a developmental disability. Review of the medical record revealed a diagnosis of unspecified psychosis not due to a substance or known physiological condition dated 09/27/17, and a diagnosis of unspecified dementia, unspecified severity with agitation dated 10/03/22. The record had no documentation of any additional PAS Reviews were completed. Interview on 10/20/22 at 1:35 P.M. with RSC #306 verified the lack of a second screening completed for Resident #38. Based on record review and staff interview, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-25 · 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 an actual skin concern was developed in the plan of care. This affected one resident (#46) out of 18 residents sampled. The facility census was 73. Findings include: Review of medical record for Resident #46 revealed admission date of 08/19/22. Diagnoses included dementia without behaviors, chronic obstructive pulmonary disease, depression, and congestive heart failure. The admission Minimum Data Set (MDS) dated [DATE] revealed he had intact cognition and required extensive two-person assistance for bed mobility, toilet use, one person for transfers and supervision for eating. No skin alterations documented. Review of the plan of care for potential/actual impairment to skin integrity related to fragile skin was created on 09/21/22. No other skin care plans were in place. Review of a progress note for Resident #46 dated 08/19/22 revealed a large brown protruding mole to the top of the scalp which measured two centimeters by two centimeters.…

    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 before2022-10-25 · 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 medical record review, observation, and resident and staff interviews, the facility failed to ensure dependent residents were repositioned. This affected one resident (#39) out of one resident reviewed for positioning. The facility census was 73. Findings include: Review of the medical record for Resident #39 revealed an admission date of 03/20/18. Diagnoses included unspecified dementia, displaced oblique fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing (10/06/22), displaced oblique fracture of shaft of right fibula (10/06/22), unspecified disorder of adult personality and behavior, and history of falling. Review of the comprehensive minimum data set (MDS) dated [DATE] revealed Resident #39 had impaired cognition and was totally dependent on two people for bed mobility and transfers. Resident #39 had not rejected care. Review of a physician order dated 11/05/18 revealed Resident #39 needed to be checked every two hours for incontinence. Review of the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-25 · 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, policy review, and staff interview, the facility failed to ensure pressure ulcers were accurately assessed and documented treatment in place. This affected one resident (#46) out of three residents reviewed for pressure ulcers. The facility census was 73. Findings include: Review of medical record for Resident #46 revealed admission date of 08/19/22. Diagnoses included dementia without behaviors, chronic obstructive pulmonary disease, depression, and congestive heart failure. The admission Minimum Data Set (MDS) dated [DATE] revealed he had intact cognition and required extensive two-person assistance for bed mobility, toilet use, one person for transfers and supervision for eating. No skin alterations documented. Review of the plan of care for potential for pressure ulcer development on 08/20/22 due to decreased mobility. Interventions in place included a pressure relieving mattress and a cushion in the wheelchair. Review of the progress note dated 09/23/22 revealed the hospice aid…

    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 · D2022-10-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    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 medical record review, staff interview and policy review, the facility failed to ensure as-needed (PRN) psychotropic medications were limited to 14 days, and failed to ensure a physician evaluated the resident before continuing a PRN psychotropic medication. This affected two residents (#48 and #66) out of seven residents reviewed for unnecessary medications. The facility census was 73. Findings include: 1. Review of the medical record for Resident #48 revealed an admission date of 01/16/13 and a readmission date of 02/23/21 with medical diagnoses of Alzheimer's disease, anxiety disorder, dementia with behavioral disturbance, and unspecified abnormalities of gait and mobility. Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #48 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, dressing, toileting, extensive assistance of one person for hygiene, and limited assistance of one person for eating. Further review revealed she…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2020-01-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 medical record review, observations and staff interview, the facility failed to ensure fall interventions were utilized as identified in the plan of care. This affected one (#57) of one resident reviewed for falls. Additionally, the facility failed to ensure chemicals were stored in a safe manner. This had the potential to affect 77 (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #18, #19, #20, #21, #22, #25, #26, #28, #30, #31, #32, #34, #35, #38, #39, #43, #44, #45, #46, #48, #53, #54, #55, #56, #57, #58, #59, #61, #63, #65, #66, #67, #69, #70, #72, #75, #76, #77, #78, #81, #82, #83, #85, #86, #87, #88, #89, #91, #92, #93, #94, #95, #96, #97, #98, #100, #102, #103, #104, #105, #106, #258 and #259) residents the facility identified as cognitively impaired and independently mobile. The census was 107. Findings include: 1. Review of the medical record for Resident #57 revealed the resident was admitted to the facility on [DATE]. Diagnoses include Parkinson's disease, dementia, psychosis,…

    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 · Ecited before2020-01-16 · 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

    Based on observation, staff interview, and policy review, the facility failed to ensure medication was secured in the medication cart. This had the potential to affect 77 (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #18, #19, #20, #21, #22, #25, #26, #28, #30, #31, #32, #34, #35, #38, #39, #43, #44, #45, #46, #48, #53, #54, #55, #56, #57, #58, #59, #61, #63, #65, #66, #67, #69, #70, #72, #75, #76, #77, #78, #81, #82, #83, #85, #86, #87, #88, #89, #91, #92, #93, #94, #95, #96, #97, #98, #100, #102, #103, #104, #105, #106, #258 and #259) residents the facility identified as cognitively impaired and independently mobile. The census was 107. Findings include: Observation on 01/15/20 at 7:30 A.M. revealed Registered Nurse (RN) #101 was in a communal area, located next to a kitchette and a dining room, preparing medication for Resident #33. Observation of the immediate area revealed resident's were in the dining room eating and being served breakfast by dietary staff and state tested nurse aides (STNA's). RN #101 placed Resident #33's medications in a medication cup,…

    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 · E2020-01-16 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff and resident interview, review of a food temperature form and policy review, the facility failed to ensure the food was palatable and at the correct holding temperature. This had the potential to all residents residing in the facility except two (#20 and #47) residents who were ordered to receive nothing by mouth. The facility census was 107. Findings include: Observation of Oakbridge Section D with Dietary Staff #552 on 01/14/19 at 5:11 P.M. revealed the staff member plated food from the hot holding area onto a test tray. The temperature of the test tray was immediately checked which revealed the chicken temped at 106 degree Fahrenheit (F), carrots temped at 119 degrees F and mashed potatoes temped at 127 degrees F. Dietary Staff #552 and the surveyor tasted the food which did not taste warm, chicken was tough and cold. Interview with Resident #82 on 01/14/20 at 5:30 P.M. revealed her chicken for supper meal was cold and dry. Interview with Food Services Supervisor #507 on 01/14/20 at 5:45 P.M. revealed the only temperatures taken of the food prior 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
  • Potential for harm · Ecited before2020-01-16 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff and resident interview, review of a local health department inspection report, review of a facility food temperature form and policy review, the facility failed to ensure staff practiced proper hand hygiene when serving food to residents. Additionally, the facility failed to maintain safe foods temperatures for food items held in the neighborhood kitchens. This had the potential to affect all residents except for two (#20 and #47) who were ordered to receive nothing by mouth. The census was 107. Findings include: 1. Observation on 01/13/20 at 11:25 A.M. revealed Dietary Staff #500 entered Resident #28's room with a lunch tray and moved personal items from the over bed table. Dietary Staff #500 placed the tray onto the over bed table and spoke with resident about her shoes. Dietary Staff #500 proceeded to touch the tops of Resident #28's shoe. Dietary Aide #500 exited the room and proceeded to enter the kitchenette in Maple Run and began to touch dishes. Interview on 01/13/20 at 11:30 A.M. with Dietary Staff #500 provided verification she had not changed…

    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 · D2020-01-16 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview and policy review, the facility failed to provide a resident with requested dental services. This affected one (#82) of one resident reviewed for dental services. The facility identified 58 residents who receive dental services from the facility dental provider. The facility census was 107. Findings include: Review of the medical record for Resident #82 revealed the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. Diagnoses include atrial fibrillation (irregular heart beat), heart failure, diabetes mellitus type II, obstructive sleep apnea, valvular heart disease, morbid obesity, anemia, polyarthritis and acute kidney failure. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no cognitive deficits or abnormal behaviors. Extensive assistance was required for bed mobility, transfers, walking, dressing, toileting and personal hygiene. Supervision was required for locomotion 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

“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

$17,345 in federal fines across 1 penalty.

  • $17,345 — penalty dated 2025-08-14

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 HCF MANAGEMENT — 22 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 1 of 53.1-2.1 vs chain
Health inspection 1 of 52.9-1.9 vs chain
Staffing 2 of 52.8-0.8 vs chain
Quality measures 4 of 54.1≈ chain avg
The other 21 homes this chain runs (chain average 3.1★, 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
CHAD M. UNVERFERTH 12-14-11 IRRV GRANTOR TROrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 12/13/2021
DAVID V. UNVERFERTH 12-14-11 IRRV GRANTOR TROrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 12/13/2021
JEFFREY L. UNVERFERTH 12-14-11 IRRV GRANTOR TROrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 12/13/2021
JOANN C. UNVERFERTH 12-29-04 REVOCABLE TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST5%since 12/13/2021
JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KENDRA M. UOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 12/13/2021
JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KERRI A. ROOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 12/13/2021
JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KEVAN R. UNOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 12/13/2021
JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KRISTEN S.Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 12/13/2021
JOANN C. UNVERFERTH 12-31-12 IRREVOCABLE GRANTOR TRUST FBO KYLE J. UNVOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 12/13/2021
JOSEPH L. UNVERFERTH 12-15-11 IRRV GRANTOR TROrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 12/13/2021
LAWRENCE G. UNVERFERTH 12-13-11 IRRV GRANTOR TROrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 12/13/2021
R. STEVEN UNVERFERTH 12-14-11 IRRV GRANTOR TROrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 12/13/2021
CHAPPEL, MARGOIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/21/2024
KLAY, CELESTEIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2016
ROMES, KERRIIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/29/2019
SHAW, ANTHONYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/26/2015
UNVERFERTH, CHADIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2005
HCF MANAGEMENT, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/17/2025
HUNTER, RACHELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2022

CMS files one row per role, so the 31 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.

13 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.

$9.4M
Net patient revenuemost recent cost report
-5.2%
Operating marginrevenue minus expenses
$456K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 43%Medicare 13%Other / private 44%

This home reported $456K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

$324per resident / day
operating cost
$9,839per month
≈ monthly operating cost
$308per 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 365341. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-08, 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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