Majestic Care of Columbus LLC
44 S Souder Ave, Columbus, OH 43222 · For profit - Limited Liability company · 120 certified beds · (614) 228-5900 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (4/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has citations for mishandling residents’ money or property (F0567, F0569)
- it has 1 actual-harm citation
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $111,283 in federal fines (most recent 2025-01-14)
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
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 2026-03 to 2026-06, this home’s CMS overall rating held steady at 5 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 | 1.3% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 3.5% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.2% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 39.5% | 30.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.8% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.7% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 12.2% | 25.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.7% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.2% | 3.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 7.7% | 21.4% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.3% | 8.8% | 17.1% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 30% 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
| 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 66.7 residents a day — about 56% occupied, or roughly 53 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.34 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.67 hrs/resident/day on weekends vs 4.61 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.87 to 0.62 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%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · G2025-01-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, hospital record review, review of the facility's incident/accident investigation, staff interview, and policy review the facility failed to develop and implement a comprehensive, individualized and effective fall management program to prevent a fall with injury for Resident #1. Actual harm occurred on 12/01/24 at approximately 12:55 P.M. when Resident #1, who had a diagnosis of dementia, fall risk with history of falls, increased lethargy and confusion sustained an avoidable unwitnessed fall out of bed resulting in head trauma/head hematoma which required hospital treatment. Prior to this fall, the resident sustained an unwitnessed fall out of bed on 12/01/24 at 1:30 A.M. with no evidence the facility implemented timely, adequate and effective interventions/measures to prevent the additional fall with injury on the same date. The resident was hospitalized until 12/09/24. Findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with 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 · D2025-12-09 · 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 Based on record review, review of a facility self-reported incident (SRI) and staff and resident interviews, the facility staff failed to ensure a resident was treated with respect/dignity. The affected one (#23) out one resident reviewed for resident rights. The facility census was 69. Findings include: Record review for Resident #23 revealed this resident was admitted to the facility on [DATE]. Diagnoses include dementia, encephalopathy, epilepsy, multiple sclerosis, bipolar disorder, major depressive disorders. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require self-care assistance due to impaired physical mobility related to Multiple Sclerosis. Review of a facility SRI for emotional/verbal abuse dated 11/30/25 revealed on 11/27/25 at 7:00 A.M. Certified Nursing Assistant, (CNA) #94 and Resident #23 had a verbal altercation in which…
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 · D2025-12-09 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and review of a facility policy, the facility failed to ensure a resident's advanced directives matched in the paper and electronic health record. This affected one (#7) out of 26 residents in the initial sample. The facility census was 69. Findings include: Review of the medical record for Resident #7 revealed an admission date of 08/03/22. Diagnoses include Alzheimer's disease with late onset, dementia in other diseases classified elsewhere with mood disturbance, paranoid schizophrenia, and severe protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 indicating severe cognitive impairment. Review of the orders for Resident #7 revealed an order that stated, FULL CODE has as Do Not Resuscitate - comfort care (DNR-CC) but POA needs to sign, remains Full Code at this time. The banner at the top of the page of the electronic health record that indicated the code status also stated the same thing. Review of the advanced directive in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-09 · tag F0609 — failed to report abuse allegations — isolatedTimely 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, review of a facility self-reported incident (SRI), staff and resident interview and facility policy review, the facility failed to ensure allegations of abuse were timely reported to the State Agency. This affected one (#23) of one resident reviewed for abuse. The facility census was 69. Findings include: Record review for Resident #23 revealed this resident was admitted to the facility on [DATE]. Diagnoses include dementia, encephalopathy, epilepsy, multiple sclerosis, bipolar disorder, major depressive disorders. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require self-care assistance due to impaired physical mobility related to Multiple Sclerosis. Review of a facility SRI for emotional/verbal abuse dated 11/30/25 revealed on 11/27/25 at 7:00 A.M. Certified Nursing Assistant, (CNA) #94 and Resident #23 had 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.
- Potential for harm · D2025-12-09 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond 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, review of a facility self-reported incident (SRI), review of a facility investigation, staff interview and facility policy review, the facility failed to ensure a thorough investigation was completed following a potential abuse incident. This affected one (#23) of four residents reviewed for abuse. The facility census was 69. Findings include: Record review for Resident #23 revealed this resident was admitted to the facility on [DATE]. Diagnoses dementia, encephalopathy, epilepsy, multiple sclerosis, bipolar disorder, major depressive disorders. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require self-care assistance due to impaired physical mobility related to Multiple Sclerosis. Review of a facility SRI for emotional/verbal abuse dated 11/30/25 revealed on 11/27/25 at 7:00 A.M. Certified Nursing Assistant,…
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 · D2025-06-12 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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 resident funds, and interview, the facility failed to notify each resident, who received Medicaid benefits, when the amount in the resident's account reached $200 less than the Social Security Income resource limit for one person. This affected two residents (#6 and #48) out of four residents reviewed for personal funds. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 12/09/18. Diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type two diabetes, chronic combined systolic and diastolic heart failure, vascular dementia, hypothyroidism, schizoaffective disorder bipolar type, bipolar disorder, hyperlipidemia, chronic pulmonary edema, spinal stenosis, anxiety disorder, chronic respiratory failure, blindness left eye category four, muscle weakness, major depressive disorder, and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure appropriate care and services were provided, including dignity and proper technique, during routine suprapubic catheter care. This affected one (Resident #29) out of one resident reviewed for catheter care. The facility identified six residents with indwelling catheters. The facility census was 75. Findings include: Review of the medical record for Resident #29 revealed an admission date of 01/29/25 with diagnoses of obstructive and reflux uropathy, major depressive disorder, insomnia, chronic pain syndrome and history of transient ischemic attack and cerebral infarction. Review of the care plan dated 01/30/25 revealed Resident #29 was at risk for infection/complications related to the use of a suprapubic catheter with the diagnosis of obstructive uropathy. Interventions included to document catheter output every shift, anchor the catheter to gravity drainage as ordered, catheter/peri-care at least every shift and as needed, 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 · D2025-06-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff interview, and facility policy review, the facility failed to ensure pressure reducing devices were in place as ordered. This affected one (Resident #61) of three residents reviewed for pressure ulcers. The census was 75. Findings Include: Review of the medical record revealed Resident #61 was admitted to the facility on [DATE]. His diagnoses were cerebral atherosclerosis, bipolar disorder, benign prostatic hyperplasia, dementia, moderate protein calorie malnutrition, hypertension, delusional disorder, anxiety disorder, insomnia, depression, violent behavior, psychosis, visual hallucinations, and Parkinsonism. The record revealed the resident did not have any active wounds. Review of Resident #61's Minimum Data Set (MDS) assessment, dated 03/05/25, revealed he was cognitively intact. Review of Resident #61's care plan dated 06/03/25 revealed a care area related to refusal of care and skin breakdown. The care plan stated he would refuse to allow preventative…
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 · D2025-06-12 · 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 2. Review of Resident #59's medical record revealed an admission date of 01/17/25 with diagnoses including bipolar disorder, emphysema, fusion of cervical spine, spinal stenosis, other chronic pain, lumbago with sciatica, and type two diabetes mellitus, Review of Resident #59's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition and the resident received scheduled and as needed pain medications. Review of Resident #59's physician order dated 05/19/25 revealed an order for Percocet Oral tablet 325 milligrams (mg) one tablet by mouth every six hours as needed for pain. Review of Resident #59's plan of care revised 06/10/25 revealed the resident had pain related to sciatica pain radiating to legs and a chronic pain diagnosis. Interventions included administering medication as ordered, notifying the physician of unrelieved pain, observing for side effects of pain medications, observing for symptoms of non-verbal pain, offering nonpharmacological interventions, and reporting…
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 · D2025-06-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure infection control practices were implemented during routine suprapubic catheter care. This affected one (Resident #29) out of one resident reviewed for catheter care. The facility identified six residents with indwelling catheters. The facility census was 75. Findings include: Review of the medical record for Resident #29 revealed an admission date of 01/29/25 with diagnoses of obstructive and reflux uropathy, major depressive disorder, insomnia, chronic pain syndrome and history of transient ischemic attack and cerebral infarction. Review of the care plan dated 01/30/25 revealed Resident #29 was at risk for infection/complications related to the use of a suprapubic catheter with the diagnosis of obstructive uropathy. Interventions included to document catheter output every shift, anchor the catheter to gravity drainage as ordered, catheter/peri-care at least every shift and as needed, and educate resident on risks of infection and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-14 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and record review the facility failed to ensure safe and sanitary storage of food and drink items in the kitchen to prevent contamination and/or spoilage. This had the potential to affect all 74 of 74 residents residing in the facility. Findings include Observation on 01/06/25 at 10:06 A.M. of Resident #68 revealed he had consumed chocolate milk from his breakfast tray that had a dated use by 01/04/25. Observations on 01/06/25 beginning at 12:20 P.M. in the facility kitchen revealed the following: In the freezer there was a serving of what appeared to be fish that was unlabeled and undated, green beans were open and undated, chicken fingers were open and undated and chocolate chip cookie dough was open to air and undated. In the refrigerator there were jars of mustard and Worcestershire sauce which were undated as well as an unknown brown juice that was undated. A plastic container with cinnamon apples was undated. A large open bag of baby carrots was found to have a use by date of 12/16/24. There were 14 chocolate milk containers in the walk…
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 13 citations
- Potential for harm · E2025-01-14 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, residents interviews, and record review, facility failed to ensure residents' personal funds were available in a timely manner. This affected one resident (#7) and had the potential to affect 68 additional residents (#1, #2, #3, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #26, #27, #28, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #46, #47, #48, #49, #50, #51, #52, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #69, #70, #72, #73, #74, #76, #77, #130, #180, and #182) identified to have personal fund accounts with the facility. The facility census was 74. Findings include Interview on 01/06/25 at 3:12 P.M. with Resident #7 revealed a concern related to accessing money from his personal fund account maintained by the facility. The resident shared he had tried to get money ($30.00) from his account, was told he could only get $10.00 for now and that he would need to come back for the remaining $20.00. Observations from 01/06/25 at 3:15 P.M. to 4:00 P.M. revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-14 · tag F0847 — patternInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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 arbitration agreements were thoroughly explained in a language the resident/representative could understand and also failed to ensure all required components and information was included in the context of the agreement. This affected three residents (#25, #27 and #55) and had the potential to affect 23 additional residents (#19, #30, #32, #46, #55, #60, #61, #66, #70, #74, #75, #76, #77, #78, #79, #130, #180, #181, #182, #183, #184, #185, and #186) who were admitted to the facility since 08/05/24. The facility census was 74. Findings include Interview on 01/06/25 at 11:33 A.M. with the Administrator during the biannual survey entrance conference revealed the facility did not have arbitration agreements and did not have any residents that had signed an arbitration agreement. Review of the admission agreement revealed an appendices Q for optional arbitration agreements without any appendix Q provided. Interview on 01/07/25 at 1:40 P.M. with Admissions #414 revealed the facility had no arbitration agreements 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 · D2025-01-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, policy review and interview, the facility failed to provide Resident #13 necessary supervision as per the resident's plan of care to ensure the resident maintained good nutrition and decreased risk of choking during meals. This affected one resident (#13) of three residents reviewed for nutrition. The facility census was 74. Findings include: Review of the medical record for Resident #13 revealed an admission date of 04/22/21 with diagnoses including Type 2 diabetes mellitus with mild nonproliferation diabetic retinopathy and macular edema bilateral, epilepsy without status epilepticus, schizoaffective disorder bipolar type, major depressive disorder, chronic obstructive pulmonary disease, vascular dementia with agitation, anxiety disorder due to known physiological condition, gastro-esophageal reflux disease without esophagitis, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, Alzheimer's disease with early onset, hypothyroidism, age-related nuclear cataract, bilateral myopia, bilateral unspecified sequelae…
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 · D2025-01-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed timely identify and treat urinary tract infections (UTIs) for Resident #72 and Resident #59. This affected two residents (#72 and #59) of two residents reviewed for UTIs. The facility census was 74. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date of 01/23/24 with diagnoses including chronic obstructive pulmonary disease (COPD), acute embolism and thrombosis of unspecified deep veins of the lower extremities (bilateral), chronic pulmonary embolism, diverticulosis of the intestine without perforation or abscess, hydrocele, nutritional anemia, essential hypertension, obstructive and reflux uropathy, benign prostatic hyperplasia without lower urinary tract symptoms, unspecified anemia, urinary tract infection, disorders of the left external ear, age-related cataract in the left eye, enophthalmos due to trauma or surgery in the right eye, other diseases of the pharynx, dysuria, hypo-osmolality 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 · D2025-01-14 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and facility policy review, the facility failed to ensure the physician provided a rationale for the decline of a pharmacy recommended gradual dose reduction (GDR) for Resident #31 and Resident #59. This affected two residents (#31 and #59) of five residents reviewed for unnecessary medications. The facility census was 74. Findings Include: 1. Review of the medical record for Resident #31 revealed an initial admission date of 07/19/24 with the diagnoses including but not limited to Alzheimer's disease, diabetes mellitus, bipolar disorder, hypertension, anxiety disorder, hyperlipidemia, overactive bladder, sleep disorder, dementia with mood disturbance, adjustment disorder with mixed anxiety and depressed mood, and chronic pain syndrome. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Resident was coded to rejected care and wander. The assessment coded diagnoses of Alzheimer's,…
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 · D2025-01-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 properly stored to include labeling that identified the date multi-use vials were first accessed/used, and medications did not exceed the expiration date on stock medication supplies. This affected two residents (#46 and #130) of two residents admitted to the third floor after 11/14/24. The facility census was 74. Findings include: Observation with Licensed Practical Nurse (LPN) #462 on 01/08/25 at 8:22 A.M. of the medication refrigerator in the third floor medication storage room revealed an opened multi-dose vial of tuberculin skin testing solution 5TU/0.1 milliliter with a manufacturer's expiration date of January 2026. The vial was opened and undated. At the time of the observation, interview with LPN #462 confirmed the vial was opened and unlabeled with either date/time opened or date/time the vial was to expire. Interview on 01/08/25 at 10:30 A.M. with LPN #462 revealed the observed tuberculin skin testing solution vial was delivered to the facility from the pharmacy 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 · D2025-01-14 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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 policy review, the facility failed to provide adequate justification for the use of antibiotics for Resident #73 and Resident ##72. This affected two residents (#73 and #72) of five residents review for unnecessary medications. The facility census was 74. Findings Include: 1. Review of the closed medical record for Resident #73 revealed an initial admission date of 05/13/24 with the latest readmission of 06/27/24. Diagnoses included but were not limited to diabetes mellitus with diabetic retinopathy with macular edema, hypothyroidism, peripheral vascular disease, bipolar disorder, chronic kidney disease, sleep disorders, cirrhosis of liver, major depressive disorder, gastro-esophageal reflux disease, enterocolitis due to clostridium difficile (c-diff), anxiety disorder, hyperlipidemia, severe morbid obesity, hypertension, congestive heart failure, arthropathic psoriasis, lymphedema, anemia, factitious disorder imposed on self combined 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.
- Potential for harm · D2024-10-01 · tag F0624 — isolatedPrepare residents for a safe transfer or discharge from the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, review of e-mail communication, facility policy review and interview the facility failed to ensure an orderly discharge for Resident #79, when the facility did not timely inform the resident of a planned discharge and packed the resident's belongings without her knowledge or involvement. This affected one resident (#79) of three residents reviewed for discharge. The facility census was 75. Findings include Review of the closed medical record for Resident #79 revealed an admission date of 01/26/23 with diagnoses including diabetes, anxiety, delusion disorder and paranoid schizophrenia. Record review revealed the resident was discharged from the facility on 09/26/24. Record review revealed the facility issued Resident #79 a 30-day discharge notice on 05/23/24 due to the safety of individuals in the home being endangered. The notice reflected the resident would be discharged on 06/23/24 and provided the resident her rights to appeal the notice. The resident refused to sign the notice.…
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 · E2024-08-05 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and resident and staff interview, facility failed to ensure resident rooms were kept in a clean and sanitary manner for two (Residents #29 and #55) and the facility failed to ensure it maintained resident rooms in safe, homelike and well maintained condition for nine (Residents #5, #17, #20, #22, #29, #30, #41, #65, and #69) of 11 reviewed for environment. The total facility census was 75. Findings include 1. Review of the medical record for Resident #29 revealed an admission date of 07/16/20. Diagnoses included schizoaffective disorder bipolar type, anxiety, personality disorder, tremor, and anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact with a BIMS of 15 and required set up and clean up assistance with toileting. Care plan dated 07/16/23 revealed resident had exhibited behavior symptoms of refusals of care including refusing to have room cleaned and became verbally aggressive when staff entered his room 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.
- Potential for harm · E2024-03-27 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
Based on observations, resident and staff interviews, review of the facility census, review of a facility list and policy review, the facility failed to ensure air temperatures were maintained at a comfortable and safe range in the first-floor common area and first-floor dining room. Additionally, the facility failed to ensure the third-floor shower room and shower chair were maintained in a clean manner. This affected six residents (#19, #44, #45, #64, #69, and #76) who were utilizing the first-floor common area and dining area and had the potential to affect 34 residents (#46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78 and #79) who used the third-floor shower room out of 79 residents who resided in the facility. The facility census was 79. Findings include: 1. Observation of the first-floor common area on 04/18/24 at 8:50 A.M. revealed Administrative Assistant (AA) #50 was sitting at the front desk wrapped in a blanket and the area felt cold. Residents #19, #44, #64,…
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 · D2024-03-27 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure resident medications were held appropriately and were not administered. This affected one (Resident #10) out of three residents reviewed for medication administration. The facility census was 79. Findings include: Review of Resident #10's medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included absence epileptic syndrome not intractable without status epilepticus, mild cognitive impairment, heart failure, depression, hypertension, and long-term use of anticoagulants. Review of Resident #10's most recent Discharge Return Anticipated Minimum Data Set 3.0 assessment, dated 01/31/24, revealed Resident #10 received anticoagulant, antibiotic, antidepressant and diuretic medications. Review of Resident #10's Pre-Operative Instructions, dated 03/13/14, revealed the resident was having a urological procedure on 03/22/24 and should not eat or drink anything after midnight 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 · D2024-02-22 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, review of Controlled Drug Administration Records, staff interview, and facility policy review, the facility failed to ensure the administration of controlled substances was accurately documented in the medical record. This affected two (Residents #36 and #80) out of six residents reviewed for unnecessary medications. The facility census was 81. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 08/30/17 with diagnoses including schizoaffective disorder, diabetes mellitus, bipolar disease, Chronic Obstructive Pulmonary Disease (COPD), mild cognitive impairment, generalized anxiety disorder, and chronic systolic heart failure. Review of Resident #36's physician order, dated 06/01/23, for Oxycodone (narcotic pain medication used to treat moderate to severe pain) five milligrams (mg) one capsule by mouth every eight hours as needed for pain. The order had no parameters for administration. Review of Resident #36's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/08/24, revealed Resident #36 had intact…
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.
- No harm found · C2025-01-14 · tag F0922 — failed to maintain the building's systems — widespreadHave enough backup water supply for essential areas of the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interview, the facility failed to ensure an adequate water supply was maintained in case of emergency. The facility emergency water supply policy did not include provisions for how emergency water would be stored including potable and non-potable water, method for distributing water and details for how the facility shall estimate the needed volume of water. This had potential to affect all facility residents. Facility census was 74. Findings include On 01/06/25 at 11:33 A.M. interview with the Administrator revealed the facility emergency water plan was in the survey readiness binder. Review the emergency water plan revealed it included steps to take in case of a short term water shut off including boiling water and flushing water systems. A contract was later provided for Water Company (WC) #1050, the emergency water supplier. Review of the policy from WC #1050 dated 01/01/25 revealed in the event of a water emergency, WC #1050 would provide gallons of drinking water within 24 to 48 hours. The contract included, if the emergency water…
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.
- 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
$111,283 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $79,952 — penalty dated 2025-01-14
- $31,331 — penalty dated 2024-02-22
- Medicare payment denial — starting 2025-02-12 for 1 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to MAJESTIC CARE — 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.5 | +2.5 vs chain |
| Health inspection | 4 of 5 | 2.1 | +1.9 vs chain |
| Staffing | 4 of 5 | 1.7 | +2.3 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 21 homes this chain runs (chain average 2.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MDG MAJESTIC OHIO OPERATIONS HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/01/2019 |
| PRUITT, PAUL | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2023 |
| MAJESTIC MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2019 |
| MDG MAJESTIC OHIO PROPERTY HOLDINGS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2019 |
| CHAMBERLAIN, MARGARET | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/11/2023 |
| CHU, VINCENT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| REWA, ANGELA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/23/2023 |
| ROSS, TIMOTHY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| RUSSELL, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/08/2024 |
| SHATROV, ANZHELIKA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/02/2024 |
| WOLFE, ERIC | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/11/2023 |
| MARX, DAVID | Individual | ADP OF THE SNF | — | since 06/01/2019 |
CMS files one row per role, so the 23 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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.
About 87% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in OH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365754. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-09, 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.