First Community Village Healthcare Ctr
1800 Riverside Drive, Columbus, OH 43212 · Non profit - Corporation · 47 certified beds · (614) 486-9511 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $17,610 in federal fines (most recent 2025-06-23)
- its facility-reported quality-measure score sits well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.3% | 5.3% | 15.4% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 14.3% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 15.2% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 7.2% | 3.2% | 3.3% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 23.8% | 25.5% | 18.9% | worse |
| Long-stay residents with pressure ulcers | 3.1% | 3.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.9% | 21.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.3% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.6% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 82.0% | 75.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.6% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.4% | 12.9% | 12.0% | typical |
‡ 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.
70.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 262 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.2% 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 63 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 0.42 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 70.3%CMS range 64.2–76.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 7.4–13.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 68.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 60.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 61.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.6%CMS range 4.6–11.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 47 beds and averages 38.0 residents a day — about 81% occupied, or roughly 9 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 5.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.80 is at or above 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 4.66 hrs/resident/day on weekends vs 5.22 on weekdays — 11% thinner on weekends. RN hours go from 0.95 to 0.73 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% 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
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.
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.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · Gcited before2025-06-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility incident report and investigative documents, resident and staff interview, and facility policy review, the facility failed to ensure a resident was safely transferred by a mechanical lift. This resulted in Actual Harm on 01/30/25 when staff attempted to transfer Resident #16 from the bed to his wheelchair with the mechanical lift and due to poor staff transferring techniques, Resident #16 was dropped to the floor. Resident #16 was sent to the hospital and returned to the facility with the following injuries: right knee posterior cruciate ligament (PCL) avulsion fracture, right Lateral Compression (LC) 1 pelvic ring injury, sacrum fracture, and Thoracic (T)9 distraction fracture (a fracture caused by a flexion-distraction injury during a rapid deceleration event). This affected one resident (#16) of three residents reviewed for accidents/falls. The facility census…
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.
- Actual harm · Gcited before2023-07-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on medical record review, staff interview, review of the fall investigation and witness statements, review of the hospital records, and review of the manufacturer recommendations for use, the facility failed to ensure a resident was safely transferred by a mechanical lift. This resulted in Actual Harm on 03/28/23 when Resident #07 was transferred from the bed to the wheelchair with the mechanical lift when the straps to the lift pad tore and Resident #07 dropped to the floor approximately two to three feet. Resident #07 complained of coccyx and buttock pain. Subsequently, Resident #07 was sent to the local hospital where he was diagnosed with a sacral fracture. This affected one resident (#07) of one resident reviewed for accident hazards. The facility census was 34. Findings include: Review of the medical record for Resident #07 revealed an admission date of 01/28/21. Diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-23 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of facility policy, the facility failed to provide proper behavior monitoring and documented discussion of the need for psychotropic's and causes of anxiety. This affected two residents (#10 and #11) of five residents reviewed for unnecessary medications. The facility census was 31. Findings include: Review of Resident #11's medical record revealed an admission date of 05/01/25 with diagnoses including chronic obstructive pulmonary disease, severe protein-calorie malnutrition, dysphagia, systemic sclerosis, depression, osteoarthritis, chronic heart failure, and hypertension. Review of Resident #11's comprehensive Minimum Data Set (MDS) 3.0 dated 05/03/25 revealed he had intact cognition. Review of Resident #11's plan of care on 06/16/25 revealed it did not address his anxiety medication use. Review of Resident #11's mini mental score on 05/05/25 revealed no mention of anxiety concerns and no behaviors. Review of Resident #11's physician order dated 05/08/25 to 05/09/25 revealed an order for Hydroxyzine (used to help control anxiety) 25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-23 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of the medical record for Resident #54 revealed an admission date of 04/16/25 with no cognitive deficits. Diagnoses included aftercare following surgery on the digestive system, malignant neoplasm colon, and intestinal obstruction, unspecified as to partial versus complete obstruction. Resident #54 discharged from the facility to home on on 04/25/25. Review of Resident #54's Minimum Data Set, dated [DATE] indicated Resident #54 was transferred to the hospital. After surveyor intervention it was modified on 06/17/25 to indicate Resident #54 was discharged home. Interview on 6/17/25 at 10:14 A.M. with the Director of Nursing (DON) confirmed a corrected MDS for Resident #54 was submitted after surveyor intervention on 06/17/25 indicating Resident #54 was not discharged to the hospital as previously recorded, but was discharged home. Based on medical record review and staff interview, the facility failed to complete and maintain accurate resident assessments when significant changes occurred. This affected…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 and interview the facility failed to ensure dressing changes were completed as ordered by the physician. This affected one (Resident #22) out of two residents reviewed for pressure ulcers. The facility census was 31. Findings include: Review of the medical record for Resident #22 revealed an admission date of 04/14/22 with diagnoses including dementia, adult failure to thrive, protein-calorie malnutrition, stage three pressure ulcer of the sacral region, bed confinement status, full incontinence of urine and feces, and muscle contractures. Review of the care plan dated 07/25/22 indicated Resident #22 has a pressure injury of the sacrum related to terminal diagnoses, bed confinement, impaired cognition, and decreased functional mobility. Interventions included administering and completing preventative treatments and dressing changes as ordered, assessing and monitoring wound healing weekly and as needed, following facility policies for skin breakdown prevention and treatment, and hospice nurse oversight of routine dressing changes and wound care orders. 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.
- Potential for harm · Dcited before2025-06-23 · tag F0697 — failed to manage pain — isolatedProvide 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 medical record review and staff interview, the facility failed to provide parameters for as needed pain medication. This affected one (Resident #16) of five residents reviewed for unnecessary medications. The census was 31. Findings Include: Resident #16 was admitted to the facility on [DATE]. His diagnoses included but were not limited to osteoporosis, spastic hemiplegia, morbid obesity, Type II diabetes, pneumonia, spinal stenosis, coronary atherosclerosis, chronic embolism and thrombosis, chronic kidney disease, cerebral infarction, mood disorder, peripheral vascular disease, anemia, nicotine dependence, acute kidney failure, epilepsy, insomnia, hyperlipidemia, and anxiety disorder. Review of his Minimum Data Set (MDS) assessment, dated 02/06/25, revealed he was cognitively intact and dependent on staff for transfers. Review of Resident #16's physician orders, dated September 2024 to June 2025, revealed an order for Acetaminophen (analgesic) 325 milligrams (mg), two tablets every four hours as needed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-09 · tag F0697 — failed to manage pain — isolatedProvide 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 record review, review of the facility policy, and physician and staff interview, the facility failed to monitor the effectiveness of the pain interventions for a resident per the resident's plan of care and professional standards of practice. This affected one (Resident #35) of three residents reviewed for pain management. The facility census was 33. Findings include: Review of the medical record for Resident #35 revealed an admission date of 11/07/23 and discharge date [DATE]. Diagnoses included spinal cerebrospinal fluid leak, spinal fusion, and spondylolisthesis lumbosacral region. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact. Review of the hospital records prior to admission revealed the resident was admitted to the hospital on [DATE] and had spinal surgery 11/01/23. Review of the hospital after visit summary (AVS) dated 11/07/23 revealed the discharge recommendation was to start taking Oxycodone (narcotic pain medication) one tablet by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-07-24 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, review of the tray line temperature log, and policy review, the facility failed to serve foods at the appropriate temperature. This had the potential to affect all residents who ate food in the facility. The census was 34. Findings included: Observation on 07/19/23 at 11:33 A.M. revealed Diet Tech (DT) #90 taking the temperature of foods prior to meal service. DT #90 pulled a hot dog that was ready to serve from the tray line and its temperature was 150 degrees Fahrenheit (F). DT #90 tested two other hot dogs with temperatures of 140 degrees F and 120 degrees F. After reheating the hot dogs for eight minutes, the temperature was 168 degrees F. DT #90 taking the temperature of a hamburger patty from the tray line that was ready to serve and the temperature was 158 degrees F. DT #90 took the temperature of the coleslaw which was 53 F degrees and the fruit cocktail was 57 degrees F. Interview on 07/19/23 at 11:33 A.M. with DT #90 confirmed the hotdog temperature were 120 to 160 degrees F, the hamburger was 158 degrees F, the coleslaw was 53 degrees F,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-07-24 · tag F0809 — failed to serve meals on a reasonable schedule — widespreadEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident and staff interviews, review of the meal times, and policy review, the facility failed to ensure meals were provided timely. This affected all 34 residents who ate meals in the facility. The facility census was 34. Findings include: Observation on 07/17/23 at 12:00 P.M. revealed a sign posted by dining room revealed lunch was to be served at 11:45 A.M. There were seven residents sitting in the dining room waiting for the meal service. Observation 07/17/23 at 12:20 P.M. no residents had received lunch meal trays in the dining room or room trays. Observation on 07/17/23 at 12:24 P.M. revealed the first of four meal carts was delivered to dining room. No drinks had been served prior to the meal tray arrival. Observation on 07/17/23 at 12:34 P.M. revealed staff started serving lunch trays to the residents. Observation on 07/17/23 at 12:34 P.M. revealed Residents #09 was sitting at the dining room table and had not received a lunch tray with all the other residents. Resident #27 was sitting at a separate table and also had not received his lunch tray.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-07-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the facility failed to store and serve food in a sanitary manner to prevent potential contamination. This had the potential to affect all 34 residents who eat in the facility. Findings included: 1. Observation on 07/17/23 at 9:56 A.M. revealed an undated tub of coleslaw and an uncovered and undated container of fruit in the tray line refrigerator. Interview on 07/17/23 at 9:56 A.M. with Director of Dietary Services (DDS) #87 confirmed the coleslaw and fruit were not dated and the fruit was uncovered. 2. Observation on 07/17/23 at 9:58 A.M. revealed a large tub of flour which was undated. Interview on 07/17/23 at 9:58 A.M. with DDS #87 confirmed the tub of flour was undated. 3. Observation on 07/17/23 at 10:05 A.M. revealed a tray of bread and a box of freezer burnt chicken uncovered in the walk-in freezer. Interview on 07/17/23 at 10:05 A.M. with DDS #87 confirmed the tray of bread and box of freezer burnt chicken were uncovered. 4. Observation on 07/17/23 at 10:09 A.M. revealed one full half-gallon of buttermilk and one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-07-24 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 resident record review, observation, staff interviews, review of the infection control logs, and policy review, the facility failed to ensure infection control logs were completed for tracking trends and patterns. This had the potential to affect all 34 residents who reside in the facility. In addition, the facility failed to follow proper infection control policies and procedures during catheter care. This affected one resident (#24) of one resident reviewed for catheter care. The facility census was 34. Findings include: 1. Review of the Infection Control Logs dated April, May, and June 2023 revealed the logs lacked tracking of the disease organism, isolation type identification, and culture dates. For months May and June 2023, there was no mapping of the house-acquired infections (HAI) or mapping of the organism in the facility. For all three months, the logs did not indicate which infections were in-house acquired infections, did not include culture dates or isolation types, and were inconsistent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-07-24 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews, staff interview, and policy review, the facility failed to monitor antibiotic use appropriately as part of an antibiotic stewardship plan. This had the potential to affect all 34 residents. The facility census was 34. Findings Include: Review of documents dated April, May, and June 2023, provided by the Director of Nursing (DON), revealed there was no documentation and analysis of appropriate indications for the use of antibiotics. Interview on 07/20/23 at 2:45 P.M. with the DON confirmed the facility used McGreer's criteria for the antibiotic stewardship program. The DON had no evidence how the facility was monitoring antibiotic medications using the McGreer criteria. The DON verified there was no documentation of an antibiotic stewardship program. The DON stated she had only been in the position for approximately three weeks and had identified antibiotic stewardship as an area of improvement for the facility. Review of the facility policy, Antibiotic Stewardship Program Policies and Procedures Annual Authorization, dated 01/20/23, revealed the policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · E2023-07-24 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the self reported incidents, and policy review, the facility failed to ensure resident abuse, neglect and misappropriation allegations were thoroughly investigated. This affected four residents (#138, #142, #141, and #143) of six residents reviewed for abuse. The facility census was 34. Findings include: 1. Record review revealed Resident #143 admitted to the facility on [DATE] with diagnoses including aftercare following joint replacement surgery, stress fracture right ankle, alcohol abuse with alcohol-induced anxiety disorder, depression, atrial fibrillation, type 1 diabetes, and conductive bilateral hearing loss. Review of a self-reported incident (SRI) for an allegation of misappropriation revealed Resident #143 reported she had an iPad charger when she admitted to the facility but was no longer able to locate it. Resident #143's room was searched, as were surrounding rooms and the laundry room. The facility interviewed staff which lead to no reports…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-24 · tag F0800 — patternProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview and menu review, the facility failed to ensure diets met the needs of residents. This had the potential to affect four residents (#07, #10, #13, and #22) who received a mechanically altered diet in the facility. The facility census was 34. Findings included: Review of the menu for lunch on 07/19/23 revealed the facility planned to serve grilled cheeseburgers, grilled hot dogs on a bun, Boston baked beans, soft potato salad, creamy coleslaw, and fresh fruit salad. Observation of the tray line on 07/19/23 at 12:00 P.M. revealed residents receiving a pureed diet were receiving pureed hamburger, with no cheese or bun, served with one 3.25-ounce scoop, two ounces of baked beans, and a container of apple sauce. Residents' with a mechanical soft diet were served a chopped cheeseburger with no bun. Interview on 07/19/23 at 12:15 P.M. with Director of Dietary Services (DDS) #87 confirmed residents with a pureed diet did not receive a bun, coleslaw, sweet potato salad, or fruit cocktail and that residents receiving mechanical soft texture did not receive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-24 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, staff interview and menu review, the facility failed to follow the menu. This affected four residents (#07, #10, #13, and #22) out of four residents on a mechanical altered diet. The facility census was 34. Findings included: Review of the menu for lunch on 07/19/23 revealed the facility planned to serve grilled cheeseburgers, grilled hot dog on a bun, Boston baked beans, soft potato salad, creamy coleslaw, and fresh fruit salad. Observation of the tray line on 07/19/23 at 12:00 P.M. revealed residents receiving a pureed diet were receiving pureed hamburger, with no cheese or bun, served with 3.25-ounce scoop, two ounces of baked beans, and a container of apple sauce. Resident with a mechanical soft diet were served a chopped cheeseburger with no bun. Interview on 07/19/23 at 12:15 P.M., with the Director of Dietary Services (DDS) #87 confirmed residents with a pureed diet did not receive a bun, coleslaw, sweet potato salad, or fruit cocktail and that residents receiving mechanical soft texture did not receive a bun with their chopped cheeseburger.
- Potential for harm · D2023-07-24 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the beneficiary notices, staff interview, review of the State Operations Manual, and policy review, the facility failed to ensure residents were provided appropriate beneficiary notices when Medicare part A services were reduced or discontinued and the residents remained in the facility. This affected two residents (#24 and #30) out of three residents reviewed for beneficiary notices. The facility census was 34. Findings Include: 1. Review of the medical record for Resident #24 revealed an admission date on 01/10/23. Diagnoses included type II diabetes, Parkinson's, dementia, muscle weakness, and a history of falling. Review of Resident #24's census revealed the resident had a Medicare part A payer source from 01/10/23 until 03/13/23. Effective 03/13/23, Resident #24 changed to a private pay payer source and remained in the facility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 had impaired cognition and scored a ten…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-24 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility document review, the facility failed to notify the ombudsmen of a resident's discharge from the facility. This affected two residents (#05 and #27) out of two residents reviewed for hospitalization. The facility census was 34. Findings include: 1. Review of the medical record for Resident #27, revealed an admission date of 04/18/2022. Diagnoses included: chronic kidney disease, stage four, metabolic encephalopathy, chronic respiratory failure with hypoxia, and dependence on renal dialysis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had impaired cognition. Review of the nurse progress note dated 07/10/23 at 4:05 P.M. revealed Resident #27 went for dialysis appointment this morning and has not returned this nurse called the dialysis center to ask for patient this nurse was told that patient was admitted to ohio state university teaching hospital. family notified. Review of Resident #27's paper and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-24 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 facility document review, the facility failed to provide a bed hold notice to resident or resident representative. This affected one resident (#27) of three residents reviewed for hospitalizations. The facility census was 34. Findings include: Review of the medical record for Resident #27, revealed an admission date of 04/18/2022. Diagnoses included: chronic kidney disease, stage 4, metabolic encephalopathy, chronic respiratory failure with hypoxia, dependence on renal dialysis, hypertension chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease and type 2 diabetes mellitus with hyperglycemia with a code status of FULL CODE and no known allergies. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a BIMS score of 05, special treatments, procedures, and programs with dialysis triggered, bed mobility/toileting is extensive assistance with two+ persons…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-24 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 medical record review, staff interview, and policy review, the facility failed to develop comprehensive care plans for resident specific care needs. This affected three residents (#13, #08, and #20) out of thirteen residents reviewed for comprehensive care plans. The facility census was 34. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 06/13/23. Diagnosis included fracture of the right acetabulum sequela, difficulty walking, moderate protein-calorie malnutrition, and adult failure to thrive. Review of Resident #13's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating an intact cognition for daily decision making abilities. Resident #13 required extensive assistance from one staff member for bed mobility and transfers. No impairments noted to residents bilateral upper or lower extremities. Resident #13 is noted to be frequently incontinent of bowel and bladder function.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure residents fluid intake was adequate to meet their nutritional needs. This affected one resident (#13) out of two residents reviewed for nutritional support. The facility census was 34. Findings include: Review of the medical record for Resident #13 revealed an admission date of 06/13/23. Diagnosis included fracture of the right acetabulum sequela, difficulty walking, moderate protein-calorie malnutrition, and adult failure to thrive. Review of Resident #13's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating an intact cognition for daily decision making abilities. Resident #13 required extensive assistance from one staff member for bed mobility and transfers. No impairments noted to residents bilateral upper or lower extremities. Resident #13 was frequently incontinent of bowel and bladder function. Resident #13 had one stage one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents oxygen tubing and humidifiers were labeled and dated. This affected three residents (#08, #20 and #148) out of three residents reviewed for respiratory services. The facility identified eight residents (#04, #06, #08, #11, #14, #20, #21, and #148) who were receiving oxygen. The facility census was 34. Findings include 1. Review of the medical record for the Resident #08 revealed an admission date of 05/27/23. Diagnoses included wedge fracture of lumbar vertebra, heart failure, chronic kidney disease, and fibromyalgia. Review of the physician orders dated 05/27/23 revealed Resident #08 had oxygen via nasal cannula at two liters per minute and to change oxygen tubing weekly on Saturday. Review of the plan of care dated 07/03/23 revealed Resident #08's oxygen was not care planned. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #08 was cognitively intact and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-24 · tag F0697 — failed to manage pain — isolatedProvide 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 medical record review, resident and staff interview, and policy review, the facility failed to ensure the physician was updated on residents uncontrolled pain. This affected one resident (#13) out of three residents reviewed for pain management. The facility census was 34. Findings include: Review of the medical record for Resident #13 revealed an admission date of 06/13/23. Diagnosis included fracture of the right acetabulum sequela, difficulty walking, moderate protein-calorie malnutrition, chronic pain and adult failure to thrive. Review of Resident #13's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating an intact cognition for daily decision making abilities. Resident #13 required extensive assistance from one staff member for bed mobility and transfers. No impairments noted to residents bilateral upper or lower extremities. Resident #13 was frequently incontinent of bowel and bladder function. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-24 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the hospital continuity of care form, review of a pharmacy faxed correspondence, and interview, the facility failed to properly monitor a resident on antibiotics and prescribe medications as ordered. This affected one resident (#20) of two residents reviewed for antibiotic use. This had the potential to affect five residents (#09, #10, #13, #20, and #244) who were receiving antibiotics in the facility. The facility census was 34. Findings included: Record review revealed Resident #20 admitted to the facility on [DATE] with diagnoses including meningitis, acute diastolic congestive heart failure, hypertensive heart disease with heart failure, chronic respiratory failure, gastro-esophageal reflux disorder, obstructive sleep apnea, hypothyroidism, hyperlipidemia, unspecified dementia without behavioral disturbance, and osteoarthritis. Review of the hospital paperwork revealed Resident #20 started vancomycin 1000 milligrams every 12 hours for 14 days intravenously on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-24 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, staff interview, observation, and policy review, the facility failed to ensure resident medications were administered with less than five percent error rate. There were two medication errors out of 25 opportunities for error with a calculated error rate of eight percent. This affected two residents (#11 and #17) out of four residents observed during medication administration. The facility census was 34. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 06/05/23 with a re-entry date of 06/25/23. Diagnosis included joint replacement, atrial fibrillation, hypertension, hemarthrosis of the right hip, and muscle weakness. Review of Resident #11's medication administration record (MAR) for July 2023 revealed an order dated 07/20/23 for a slow-release iron oral tablet, extended release 160 milligrams (mg). Give one tablet by mouth once a day for iron deficiency. Review of Resident #11's MAR for July 2023 revealed Licensed Practical Nurse (LPN) #112 marked ON on the date 07/20/23 for the Slow Release Iron 160 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.
- Potential for harm · Fcited before2020-03-05 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, review of facility policy and procedures, the facility failed to implement their Water Management Plan to reduce the risk, growth and spread of the Legionella Disease. This had the potential to affect all 45 residents of the facility. Findings include: Interview on 03/03/20, at 11:12 A.M. with the Maintenance Supervisor (MS) #368 revealed he took resident rooms water temperatures daily, however, did not keep a record of the temperatures. Interview on 03/03/20, at 2:36 P.M. with MS #368 and Executive Director (ED) #376 revealed they did not flush systems that had standing water. The ED revealed they had a contracted company who tested their water systems two times a year for the Legionella infection. Interview on 03/04/20, at 11:30 A.M. with the Executive Director #376 confirmed they do not have documentation of performing the required maintenance measures listed in their Water Management Plan. Review of the Legionella Policy-Environmental Policy and Procedure (February 2018) revealed the mission of the facility is to maintain environmental and clinical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-03-05 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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. Medical record review revealed Resident #43 was admitted to the facility 09/07/16 with diagnoses including dementia without behavioral disturbance. Review of the MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Observations on 03/02/20 at 10:16 A.M., on 03/03/20 at 8:37 A.M., and on 03/04/20 at 8:38 A.M. revealed Resident #43 in her wheelchair in the dining room. Her wheelchair had two strips of pink tape and one strip of blue tape with her first initial of her first name, and full last name taped to the back of her chair. Interview on 03/04/20 at 11:35 A.M. with State Tested Nursing Assistant (STNA) #211 confirmed Resident #43 had two strips of pink duct tape and one strip of blue painter's tape with her first initial of her first name, and full last name on her wheelchair. The STNA confirmed it was not dignified to have tape on the back of Resident #43's wheelchair with her name on it. Based on medical record review, observation, resident interview, staff interview, 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$17,610 in federal fines across 1 penalty.
- $17,610 — penalty dated 2025-06-23
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FCV CORPORATION | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/30/2003 |
| ADCOCK, HEATHER | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| BARKIN, VICTORIA | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| BLOOMFIELD, SALLY | Individual | CORPORATE DIRECTOR | — | since 01/01/2019 |
| DAVIS, JOHN TERRANCE | Individual | CORPORATE DIRECTOR | — | since 01/01/2019 |
| HOFF, ANGELA | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| METTLER, BRIANNA | Individual | CORPORATE DIRECTOR | — | since 01/01/2024 |
| ALEXANDER, SEAN | Individual | CORPORATE OFFICER | — | since 01/01/2025 |
| DEHRING, LINDSEY | Individual | CORPORATE OFFICER | — | since 07/01/2024 |
| MEYUNG, KELLI | Individual | CORPORATE OFFICER | — | since 07/01/2024 |
| RULE, MATTHEW | Individual | CORPORATE OFFICER | — | since 04/01/2019 |
| WOOLLEY, JULIE | Individual | CORPORATE OFFICER | — | since 01/01/2022 |
| NATIONAL CHURCH RESIDENCES HEALTH CARE | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2010 |
| MACPHERSON, GREGORY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| PATEL, BHAVESH | Individual | ADP OF THE SNF | — | since 12/29/2025 |
CMS files one row per role, so the 16 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $636K 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365047. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-23, 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.