No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Ohio Living Westminster-Thurber

717 Neil Avenue, Columbus, OH 43215 · Non profit - Corporation · 35 certified beds · (614) 228-8888 Medicare & Medicaid certified

Call the home — (614) 228-8888 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 2026Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding 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 (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • nursing-staff turnover (59%) runs well above the national median (45%)

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 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 staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
535 Reach Blvd Ste 200 · (614) 451-2280 · Call to confirm hours
Pharmacy
759 Neil Ave · (614) 224-9275 · Call to confirm hours
Grocery
777 Neil Ave · (614) 224-3065 · Call to confirm hours
Park
Wheeler Memorial Park, 725 Thurber Dr W · (614) 645-3111 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.9%5.3%15.4%typical for the state — see note marked double-dagger below the table
Long-stay residents who lose too much weight8.2%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.0%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms5.6%30.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury8.3%3.2%3.3%worse
Long-stay residents whose ability to walk worsened8.2%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication8.2%25.5%18.9%better
Long-stay residents given the seasonal flu vaccine91.7%94.5%95.3%typical
Long-stay residents with pressure ulcers2.2%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control7.2%21.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.8%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine72.7%75.6%79.4%typical
Short-stay residents rehospitalized after admission29.2%24.9%22.6%worse
Short-stay residents with an outpatient ER visit19.7%12.9%12.0%worse

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.

69.0% 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 49 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

69.0%U.S. median 51.5%
Got home and stayed home
9.1%U.S. median 10.7%
Went back to hospital
80.0%U.S. median 56.6%
Met the expected recovery
0.60U.S. median 0.31
Therapy hours / resident / day
0.35hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 80.0% 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 20 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 0.60 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF69.0%CMS range 59.1–75.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.1%CMS range 5.7–13.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge80.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge95.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge65.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.8%CMS range 4.0–12.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.771.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.45
RN hours/ resident / day
1.24
LPN hours/ resident / day
2.49
Aide hours/ resident / day
5.18
Total nurse hours/ resident / day
0.85
RN hoursweekends
58.7%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 35 beds and averages 30.5 residents a day — about 87% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.18 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.45 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 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 4.52 hrs/resident/day on weekends vs 5.44 on weekdays — 17% thinner on weekends. RN hours go from 1.69 to 0.85 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

10
deficiencies at the latest standard inspection (2025-05-29)
5
at the previous standard inspection (2022-05-31)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · Gcited before2023-08-17 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observation, review of the hospital records, staff, family, and resident interviews, review of a Self- Reported Incident (SRI), review of the facility investigation, and review of the facility's abuse policy, the facility failed to ensure a resident was free from neglect. This resulted in Actual Harm when Resident #01 went five hours lying on the floor, crying for help, vomiting several times, suffered pain, and did not receive medical attention for approximately five hours. Subsequently, Resident #01 required an emergency transfer to the hospital, an inpatient hospital stay for seven days, and treatment for multiple fractures of the clavicle, medial and lateral left elbow, and left humerus. This affected one (Resident #01) of three residents reviewed for abuse. The facility census was 32. Findings include: Clinical record review revealed Resident #01 was…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · F2026-05-07 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interview, and policy review, the facility failed to ensure food was held and served at safe and appetizing temperatures. This had the potential to affect 32 of 32 residents who receive food from the kitchen. Facility census was 32. Findings include:Observation and interview on 05/05/26 from 11:47 A.M. to 12:10 P.M., with Kitchen Manager #81 revealed the facility was serving a turkey club sandwich (cold), coleslaw (cold), gelatin (cold) and loaded potato soup (hot) for lunch. The temperatures were taken at the time the test tray was made and found the turkey club sandwich had a temperature of 53 degrees. It was placed back in the freezer to cool and a new tray was removed from the freezer to serve and sandwiches held a temperature of 43 to 45 degrees. Kitchen Manager #81 returned the tray to the freezer and reported they needed to cool a bit more prior to service. Majority of the lunch trays for the 400 hall cart were already made and placed on the cart for service and came from the sandwich tray with a holding temperature of 53 degrees. These remained…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-07 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the medical record, review of facility investigation, review of witness statements, staff interviews, resident family interviews, and review of policy, the facility failed to ensure a resident was free from neglect, when a severely cognitively impaired nonmobile resident, who was dependent on staff for all activities of daily living (ADLS), was not provided food, drink or assistance with ADLs, including incontinence care for approximately 12 hours. This affected one (#12) of three residents reviewed for potential abuse and neglect. The facility census was 32.Findings include: Review of the medical record for Resident #12 revealed an admission date of 03/23/21. Diagnoses included Alzheimer's disease, anxiety, dementia, malnutrition, muscle weakness, contracture of the right foot, and hypertension. Review of Resident #12's Minimum Data Set (MDS) assessment, dated 04/08/26, revealed the resident was rarely if ever understood and cognition was unable to be assessed for Resident #12. The assessment indicated Resident #12 was dependent on staff assistance for all…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-07 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the medical record, review of facility investigation and witness statements, staff interviews, resident family interviews, and review of policy, the facility failed to ensure an allegation of neglect was reported to the state agency in the required timeframes. This affected one (#12) of three residents reviewed for potential abuse and neglect. The facility census was 32. Findings include: Review of the medical record for Resident #12 revealed an admission date of 03/23/21. Diagnoses included Alzheimer's disease, anxiety, dementia, malnutrition, muscle weakness, contracture of the right foot, and hypertension. Review of Resident #12's Minimum Data Set (MDS) assessment, dated 04/08/26, revealed the resident was rarely if ever understood, was severely cognitively impaired and was unable to be assessed for Resident #12. The assessment indicated Resident #12 was dependent on staff assistance for all mobility and transfers and was assessed to in be incontinent of bowel and bladder. Review of Resident #12's care plan, revised 04/09/26, revealed the resident was noted to…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the medical record, review of the facility investigation, review of witness statements, review of facility staff training email, review of staff training records, review of facility audits, staff interviews, resident family interviews, and review of policy, the facility failed to ensure a thorough investigation was completed and corrective action was implemented to correct an incident of neglect, when a severely cognitively impaired nonmobile resident, who was dependent on staff for all activities of daily living (ADLS), was not provided food, drink or assistance with ADLs, including incontinence care for approximately 12 hours. This affected one (#12) of three residents reviewed for potential abuse and neglect. The facility census was 32.Findings include: Review of the medical record for Resident #12 revealed an admission date of 03/23/21. Diagnoses included Alzheimer's disease, anxiety, dementia, malnutrition, muscle weakness, contracture of the right foot, and hypertension. Review of Resident #12's Minimum Data Set (MDS) assessment, dated 04/08/26, revealed the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-07 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the medication administration policy, the facility failed to ensure a resident was free from significant medication errors. This affected one (#34) of three residents reviewed for medication administration. The facility census was 32.Findings include: Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis (paralysis and weakness) following cerebral infarction (stroke), non-Hodgkin's lymphoma, chronic pain, and dysphagia (difficulty swallowing) amongst other diagnoses. Further review of Resident #34's medical record revealed the resident was assessed as having severely impaired cognition upon admission.Review of Resident #34's physician orders revealed an order for Oxycodone (pain medication) five milligram (mg) tablets, one tablet to be given every eight hours scheduled at 12:00 A.M., 8:00 A.M., and 4:00 P.M. with a start date of 07/02/25 and an end…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to maintain an accurate complete medical record for medication administration of narcotics to a resident. This affected one (#34) of three residents reviewed for completeness and accuracy of the medical record. The facility census was 32.Findings include:Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis (paralysis and weakness) following cerebral infarction (stroke), non-Hodgkin's lymphoma, chronic pain, and dysphagia (difficulty swallowing) amongst other diagnoses. Further review of Resident #34's medical record revealed the resident was assessed as having severely impaired cognition upon admission.Review of physician orders for Resident #34 revealed an order for a dose of 0.5 milliliters (ml) of morphine liquid concentration at a strength of 100 milligrams (mg)/5 ml to be given each day every shift as needed for pain, with a start…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-05-29 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and policy review, the facility failed to ensure proper food handling techniques when checking food temperatures. This had the potential to affect all 29 residents in the facility. Findings include: Observation on 05/28/25 at 11:35 A.M. revealed [NAME] #36 checked the temperature of the lunch meal including the pork, beef, German potato salad, peas, ground meats, and soup, in that order. Between each food checked, [NAME] #36 wiped the thermometer on a dry rag, which was resting on the steam table counter. Interview on 05/28/25 at 11:39 A.M., [NAME] #36 verified she wiped the thermometer on a dry rag between each food. [NAME] #36 stated she normally used alcohol wipes, but could not locate them when she started checking the temperatures. Interview on 05/28/25 at 11:40 A.M., Chef #57 verified alcohol wipes should have been used to clean the thermometer in between obtaining the temperature of each food. Review of the facility policy titled, Hazard Analysis Critical Control Points and Food Safety, dated 2023, revealed staff would be aware of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-05-29 · tag F0947 — failed to train nurse aides adequately — widespread
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of personnel files and staff interview, the facility failed to ensure one staff completed at least 12-hours of education each year. This had the potential to affect all residents residing in the facility. The facility census was 29. Findings include Review of the personnel file for Certified Nursing Assistant (CNA) #5 revealed they began employment on 04/06/20. Review of the training logs revealed CNA #5 had completed several training's in 10/29/23. Since 10/29/23, the CNA had only completed 6.25 hours of continuing education. The educations included a medicaid waiver education on 06/24/24 for 0.25 hours, understanding dementia on 02/02/25 for one hour, communication on 02/02/25 for one hour, challenging behavior on 02/02/25 for one hour, activity on 02/04/25 for one hour, dining on 02/04/25 for one hour, and personal care on 02/04/25 for one hour. Interview on 05/29/25 at 10:50 A.M. with Human Resources #19 confirmed CNA #5 had not completed 12 hours of education in the previous 19 months. She reported the facility completed education on a rolling calendar from July…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-29 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent 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 review of the medical record, staff interviews, and review of Food and Drug Administration (FDA) guidelines, the facility failed to ensure adequate behavioral monitoring to evaluate effectiveness and psychotropic medication necessity for Resident #136. This affected one resident (#136) of five reviewed for unnecessary medications. The facility census was 29. Findings include: Review of Resident #136's medical record revealed an admission date of 05/20/25 with diagnoses including Parkinson's Disease without dyskinesia, cognitive communication deficit, muscle weakness, major depressive disorder, type two diabetes mellitus without complications, age-related osteoporosis without current pathological fracture, history of falling, neurocognitive disorder with Lewy bodies, and severe dementia with agitation. Review of Resident #136's Minimum Data Set (MDS) assessment completed on 05/28/25, revealed the resident was dependent on staff for upper and lower body dressing, toileting and showering. She required substantial assistance for changing positions and she was dependent 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-29 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, record review, and review of the facility policy and procedure, the facility failed to ensure an allegation of sexual and physical abuse were reported to the State agency within the required timeframe's. This affected one resident (#1) of two reviewed for abuse. The facility census was 29. Findings include: Review of the medical record for Resident #1 revealed an admission date of 05/06/21. Diagnoses included arthritis, weakness, obesity, depression, and colostomy status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 and required substantial/maximum assistance from staff members for toileting assistance. Interview on 05/27/25 at 10:11 A.M. with Resident #1 revealed a concern of staff giving rough care during incontinence care and also a report of sexual abuse. Resident #1 reported Certified Nursing Aide (CNA) #200 had, on one occasion, provided rough care…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2025-05-29 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure care conferences were completed as required. This affected two (#6 and #18) of two residents reviewed for care conferences. This had the potential to affect all 29 residents in the facility. Findings include: Review of the medical record of Resident #18 revealed an admission date of 04/11/24. Diagnoses included major depressive disorder with psychotic symptoms, myotonia congenita, and age-related physical debility. Review of Resident #18's care conferences revealed they were held for the resident on 04/12/24, 07/31/24, and 04/25/25. Review of Resident #18's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Interview on 05/27/25 at 9:35 A.M. with Resident #18 revealed she only recalled having a care conference about a year prior. Interview on 05/28/25 at 10:17 A.M., Director of Social Services (DSS) #38 stated care conferences were to be held…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-29 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review, and staff interviews, the facility failed to follow podiatry recommendations. This affected one resident (Resident #16) out of one resident reviewed for limited range of motion. The facility census was 29. Findings include: Review of Resident #16's medical record revealed an admission date of 06/03/15. Medical diagnoses included right foot talipes equinovarus (a club-like deformity), hemiplegia, mild cognitive impairment, muscle weakness, and marked limited ambulation. Review of the Minimum Data Set (MDS) assessment completed on 04/29/25 revealed Resident #16 had intact cognition and was independent with eating, oral hygiene, showering, and dressing. He required partial to moderate staff assistance with toileting and was dependent on a manual wheelchair for mobility due to a severe foot deformity and the inability to walk. Review of Resident #16's care plan dated 02/05/24 included a goal that the resident would receive the appropriate staff support with all functional abilities and interventions to include mobility devices as ordered. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-29 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of facility policy, the facility failed to ensure timely follow-up of pharmacy recommendations. This affected one (Resident #24) out of five residents reviewed for pharmacy recommendations. The facility census was 29. Findings include: Review of the medical record for Resident #24 revealed the resident was admitted on [DATE] with diagnoses including Parkinson's disease, dementia, atherosclerotic heart disease, bradycardia, coronary artery disease (CAD), chronic diastolic heart failure, and hyperlipidemia. Review of the care plan dated 12/31/19 revealed the resident had cardiopulmonary/circulatory/coronary conditions with interventions that included to administer medications as ordered. Review of physician orders dated 03/01/24 revealed Resident #24 was prescribed Aspirin 81 milligrams (mg) daily for CAD. Review of Resident #24's progress note dated 07/16/24 documented a monthly medication regimen review was completed with recommendations made. Review of 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-29 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 observations, medical record review, hospice record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure hospice communication/documentation was maintained by the facility. This affected one (Resident #6) of one reviewed for hospice services. The facility census was 29. Findings include Review of the medical record for Resident #6 revealed an admission date of 06/17/17. Diagnoses included psychotic disorder with delusions, muscle weakness, dementia, malnutrition, delusion disorder and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively impaired. It noted he was dependent on staff assistance for bed mobility, and required total dependence of one staff for eating. Review of physician orders for Resident #6 revealed an order dated 09/14/23 for admission to hospice services. Review of Resident #6's hospice episode detail report dated 03/27/25 revealed a summary of hospice orders. Review of…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-29 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure sanitary practices were performed during medication administration. This affected three residents (#22, #29, and #136) out of twelve observed during medication administration. The facility census was 29. Findings include: 1. Review of the medical record for Resident #29 revealed an admission date of 12/23/24 with diagnoses including pulmonary hypertension, gastro-esophageal reflux disease with esophagitis, hypertension, cardiomegaly, and chronic systolic heart failure. Review of the care plans dated 01/02/25 and 03/10/25 revealed Resident #29 had chronic cardiopulmonary and gastrointestinal conditions, with an approach to administer medications as ordered by the physician. Review of physician orders dated 03/26/25 revealed an order for Carvedilol 6.25 milligrams (mg), one tablet, scheduled between 10:00 A.M. and 1:00 P.M. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 had no cognitive…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-29 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement 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 record review, staff interview, review of the infection control log, and review of facility policy and procedure, the facility failed to follow its antibiotic stewardship protocol by administering antibiotics without meeting established clinical criteria. This affected two (Resident #17 and Resident #32) of three residents reviewed for antibiotic use. The facility census was 29. Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 02/21/25 with diagnoses including vascular dementia, dysphagia, cystitis, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #17 showed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Resident #17 required substantial to maximal assistance with toileting hygiene and was documented as always incontinent of bowel and bladder. Review of the care plan dated 02/26/25 for Resident #17 identified bowel 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 staff interviews and medical record review, the facility failed to regularly assess a resident's catheter routinely per the resident's plan of care. This affected one (Resident #4) of three residents reviewed for catheter care. The facility census was 30. Findings include: Review of the medical record for Resident #4 revealed a readmission on [DATE]. Diagnoses included neurogenic bladder and retention of urine. Review of the care plan dated 06/11/24 for Resident #4 revealed the need for an indwelling urinary catheter due to urinary retention. Interventions included assessing the drainage every shift, recording the amount, type, color, and order, observing for leakage, encouraging fluid intake, and providing catheter care every shift as needed. The physician orders dated 07/31/24 revealed to change indwelling Foley catheter and keep in place. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/07/24, revealed Resident #4 was severely cognitively impaired, and required partial/moderate…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-05-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and review of facility policy, the facility failed to properly store an oxygen E cylinder. This had the potential to affect 79 residents residing in the health center. The facility census was 100. Findings Include: Observation of the main entrance during survey entry on 05/23/22 at 8:30 A.M. revealed there were six oxygen E cylinders in a holder, one oxygen E cylinder free standing and six small oxygen cylinders in a holder. The free standing oxygen E cylinder had a regulator on the tank, indicating the tank was 1/2 full. Interview on 05/23/22 at 10:46 A.M. Secretary #108 verified there was an E cylinder not in a holder in the main entry way. Secretary #108 stated she was not sure why the tanks were sitting in the entry, but verified the tanks in holders had been in the same spot since February 2022, when she started working for the facility. Secretary #108 stated she was not sure how long the free standing tank had been in the entry area. Secretary #108 verified the main entry, where the oxygen cylinder was free standing, was the entry where…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-31 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure Resident #52 was provided a homelike environment. This affected one resident (#52) out of four residents reviewed for environment. Facility census was 100. Findings include: Review of the medical record revealed Resident #52 was admitted on [DATE] with diagnoses including encephalopathy, visual hallucinations, pseudobulbar affect, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had severe cognitive impairment. Observation on 05/23/22 at 11:30 A.M. revealed Resident #52's headboard and footboard was off the bed. The footboard was leaning against the built in drawers at the end of the bed. The headboard was leaning against the wall near the head of the bed. There were long, deep gouges in the wall at the head of the bed. Interview on 05/24/22 at 2:55 P.M. Housekeeper #100 verified Resident #52's headboard had been off the bed for at least a week. Interview on 05/24/22 at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-31 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility staff interview, and review of facility policy, the facility failed to monitor a resident's blood pressure and heart rate with the administration of blood pressure medication, as ordered. This affected one (#23) of five residents reviewed for medications with parameters. The facility census was 100. Findings include: Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's, heart failure, hypertension, diabetes, hyperlipidemia, and dementia. Review of the most recent quarterly Minimum Data Set (MDS) assessment revealed the resident had mild cognitive impairment and no behaviors. The resident required extensive assistance for activities of daily living. Review of physician orders revealed an order dated 12/21/21 for Carvedilol (anti-hypertensive) 6.25 milligrams (mg) by mouth, twice daily for congestive heart failure, hold for systolic blood pressure less than 110 and heart rate less than 55.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-31 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to monitor behavioral symptoms for a resident who recieved psychotropic medication. This affected one (#23) of five residents reviewed for unnecessary medications. The facility census was 100. Findings Include: Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's, heart failure, hypertension, diabetes, hyperlipidemia, and dementia. Review of the most recent quarterly Minimum Data Set (MDS) assessment revealed the resident had mild cognitive impairment. The resident had no behaviors, hallucinations, or delusions during the review period. Review of physician orders revealed an ordered dated 12/21/21 for Seroquel (anti-psychotic) 12.5 milligrams (mg) daily for hallucinations related to Parkinson's. Further review of Resident #23's medical record revealed no evidence the resident's behaviors/hallucinations were monitored. Interview on 05/24/22 at 4:29 P.M.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-31 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident received medications as ordered. This affected one (#46) of five residents reviewed for receiving medications as ordered. The facility census was 100. Findings Include: Medical record review for Resident # 46 revealed the resident admitted to the facility on [DATE], with diagnosis including end stage renal disease, hypertension, monoclonal gammopathy, dependent on dialysis and cirrhosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment with no behaviors noted. The resident required limited assistance with activities of daily living (ADLs). Resident #56 had end stage renal disease and was dependent on dialysis. Review of Resident #46's physician orders revealed the resident had orders for Dialysis on Tuesdays, Thursdays, and Saturdays at 8:00 A.M. Review of physician order dated 04/07/22 revealed an order for Sevelamer carbonate…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2019-08-01 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and review of facility policies, the facility failed to ensure infection control practices were followed in the kitchen. This had the potential to affect 116 of 118 residents who receive food from the kitchen. The facility identified two residents (#102 and #104) who received nothing by mouth. The facility census was 118. Findings include: 1. Observation on 07/29/19 at 8:36 A.M., revealed dented cans of prunes, peaches, great northern beans, and jellied cranberry sauce stored on the shelf in the dry storage area. At 8:41 A.M., an observation of the cooler revealed a container of parmesan cheese with a use by date of 07/06/19. Interview with Chef/Production Manager (CPM) # 202 on 07/29/19 at 8:45 A.M., verified the above observations. 2. Observation on 07/29/19 at 12:30 P.M., revealed CPM #202 and [NAME] #206 were in the food preparation area without wearing facial hair protectors. They both at the time of the observation verified they should be wearing a facial hair protector while in the food preparation area but were not. 3. Observation 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-08-01 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical record, review of hospital records, staff interview, and review of facility policy, the facility failed to ensure a resident had a supporting diagnosis for use of an antipsychotic medication. This affected one resident (#102) of five residents reviewed for unnecessary medications. The facility census was 118. Findings include: Review of medical record revealed Resident #102 was admitted to the facility on [DATE]. Diagnoses included anoxic brain damage, other symbolic dysfunctions, type two diabetes with neuropathy, other specified anxiety disorders, major depressive disorder, and vascular dementia with behavioral disturbance. Review of Resident #102's hospital record dated 06/07/19 through 06/14/19 revealed no evidence the resident had a diagnosis of bipolar disorder. Review of comprehensive assessment dated [DATE] revealed the resident was rarely or never understood and the mental status interview was not conducted. The resident did not have indicators of potential psychosis and did…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-01 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview and review of the medication safety alert for insulin pen use, the facility failed to ensure their medication error rate was less than 5%. Two medication errors were noted out of 28 opportunities for a medication error rate of 7.14%. This affected one resident (#64) of three residents observed for medication administration. The facility census was 118. Findings include: Observation of medication administration on 07/31/19 at 8:38 A.M., revealed Licensed Practical Nurse (LPN) #207 prepared medications for Resident #64 which included insulin injections. A Lantus and Novolog Flex pen were prepared by the nurse. The nurse first prepared the Lantus insulin syringe by placing a needle onto the syringe. She dialed one unit and pressed the button on the syringe to prime the needle holding the needle in a horizontal manner. She then dialed 18 units of insulin. She then prepared the Novolog Flex pen in the same manner by priming the needle with 1 unit holding the pen in a horizontal position. She then dialed 8 units on the pen. The nurse confirmed at the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-01-02 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews with staff, the facility failed to ensure that the kitchenette rodent traps were properly maintained and disposed of in a timely manner. This had the potential to affect all 16 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #19, #11, #12, #13, #14, #15 and #16) who received food from the third floor kitchenette. The facility census was 30. Findings include: Observation of third floor kitchenette on 12/31/24 at 9:43 A.M. revealed a deceased mouse in a sticky trap near the dishwasher. There was a large hole in the drywall beneath the sink, with a visible metal guard trim, which allowed easy access to the kitchen and the movement of rodents between floors. Subsequent observations of the third floor kitchen on 12/31/24 at 11:07 A.M., 12:58 P.M. and 5:02 P.M. the mice had not been identified by staff. The observation on 12/31/24 at 12:58 P.M. during lunch service revealed Certified Nursing Assistant (CNA) #53 and CNA #94 were serving lunches to resident. They also needed to collect ice from the kitchenette, which they frequented during meal…

    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.

    Environmental Deficiencies · Deficient, Provider has plan of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to OHIO LIVING COMMUNITIES — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 54.4-1.4 vs chain
Health inspection 2 of 53.5-1.5 vs chain
Staffing 4 of 54.0≈ chain avg
Quality measures 5 of 54.9≈ chain avg
The other 10 homes this chain runs (chain average 4.4★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
ADAM, SANDRAIndividualCORPORATE DIRECTORsince 10/01/2019
BELFANCE, LESLIEIndividualCORPORATE DIRECTORsince 01/01/2023
INGWERSEN, MELISSAIndividualCORPORATE DIRECTORsince 07/01/2022
JOYCE, JAMESIndividualCORPORATE DIRECTORsince 07/01/2020
WHITE, TERRYIndividualCORPORATE DIRECTORsince 10/01/2019
GUMINA, LAURENCEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 12/12/2015
STILLMAN, ROBERTIndividualCORPORATE OFFICERsince 04/15/2013
THORPE, REBECCAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
MACK, DONALDIndividualADP OF THE SNFsince 01/21/2020

CMS files one row per role, so the 11 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

$4.5M
Net patient revenuemost recent cost report
-25.1%
Operating marginrevenue minus expenses
$395K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 37%Medicare 6%Other / private 57%

This home reported $395K 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

$479per resident / day
operating cost
$14,564per month
≈ monthly operating cost
$383per day
avg. revenue, all payers

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

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365416. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-29, 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.

What to do next