Riverview
3710 Olentangy River Road, Columbus, OH 43214 · For profit - Limited Liability company · 145 certified beds · (614) 457-1100 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $168,656 in federal fines (most recent 2025-02-06)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 3.7% | 5.3% | 15.4% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who lose too much weight | 5.6% | 6.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.2% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.3% | 0.4% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 16.0% | 30.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.5% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.0% | 6.1% | 16.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents on antianxiety or hypnotic medication | 16.6% | 25.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.1% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 3.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 19.6% | 21.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.4% | 8.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 89.7% | 75.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.3% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.4% | 12.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.75 | 1.73 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.25 | 1.80 | 1.80 | 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.
57.7% 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 250 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 77.3% 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 88 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 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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 | 57.7%CMS range 51.5–62.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.5%CMS range 9.1–14.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 77.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 54.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 62.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.1%CMS range 4.6–10.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 145 beds and averages 119.5 residents a day — about 82% occupied, or roughly 26 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.14 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 3.39 hrs/resident/day on weekends vs 3.77 on weekdays — 10% thinner on weekends. RN hours go from 0.82 to 0.92 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · Lcited before2025-02-06 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of hospital records, observation, staff interviews, interview with the Local County Health Department (LCHD), interview with the physician, review of a death certificate, review of the facility's Legionella bacteria prevention plan, review of email communications with the LCHD, review of facility policy and procedures, review of the Legionella risk assessment, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to follow their water management plan to ensure all shower heads were descaled semi-annually and flushes were completed weekly which resulted in elevated risk levels of Legionella bacteria in the facility's water system and exposure to the residents. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when on [DATE] one resident (#100) was found to have increased effort of breathing, fatigue and generalized weakness, was sent to the emergency room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-02-08 · 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 observation, record review, staff interviews, review of wound notes, and facility policy review, the facility failed to accurately assess, timely notify the physician of an identified pressure area, and implement interventions to prevent a middle lumbar pressure ulcer from worsening for Resident #16. Additionally, the facility failed to comprehensively assess, notify the physician, and implement a treatment plan timely for Resident #9 and Resident #67 who were admitted to the facility with pressure ulcers/injuries. Actual Harm occurred on 10/22/23 when Resident #16, who required extensive assistance from two staff and was incontinent, had a middle lumbar wound that was not accurately assessed as a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.) pressure ulcer which worsened to an unstageable (dead or devitalized tissue that is hard or soft in texture; usually…
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 · Ecited before2025-05-01 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 review of facility policy, the facility failed to ensure that medications were stored securely. This had the potential to affect 74 residents, #1, #2, #3, #4, #7, #8, #10, #12, #13, #14, #15, #17, #20, #25, #28, #29, #32, #33, #34, #36, #37, #40, #41, #42, #43, #44, #45, #50, #51, #52, #58, #61, #62, #76, #77, #78, #79, #84, #85, #86, #88, #89, #90, #92, #93, #94, #95, #102, #103, #104, #107, #110, #112, #116, #117, #120, #121, #122, #138, #175, #178, #179, #180, #226, #227, #229, #231, and #232 The facility also failed to ensure that medications, including three cups containing various types of pills, were stored appropriately. The facility census was 120. Findings include: 1. Continuous observation on 04/30/25 from 8:44 A.M. until 8:47 A.M. revealed an unattended and unlocked medication cart on Unit #4. Registered Nurse (RN) #201 exited a room across the hall and to the left of the unlocked medication cart at 8:47 A.M. and returned to the medication cart. Interview with RN #201 on 04/30/25 at 8:47 A.M. confirmed that she had left 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 · Ecited before2025-05-01 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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, resident interview, staff interview, and review of facility policy, the facility failed to provide food and drink at a palatable, attractive, and at a safe and appetizing temperature. This affected one resident (Resident #75) and had the potential to affect all 65 of the residents on units #2 and #4 except for Resident #68 and Resident #114, who did not eat or drink food from the kitchen. The facility census was 120 residents. Findings include: 1. Review of the medical record for Resident #75 revealed an admission date of 12/24/20. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #75, dated 04/11/25, revealed that her short term and long term memories were assessed as being okay. Review of physician orders for Resident #75 dated 08/23/24 revealed the resident was on a regular diet with regular textures. Review of the plan of care dated 04/11/24 for Resident #75 revealed that she was at risk for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-01 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 distribute and serve food under sanitary conditions. This had the potential to affect all residents residing in the facility who receive food from the kitchen except for residents #68 and #114 who did not eat or drink food from the kitchen. The census was 120. Findings include: Observation and tour on 04/28/25 from 9:30 A.M. to 10:00 A.M of the kitchen with Regional Dietary Manager #400 and Dietary Manager (DM) #216 revealed the following: -One large empty plate warmer unit sitting in the service line area revealed the spring loaded plate dispenser was covered with orange and black particles and dust like substance. When wiped with a white paper towel the brown orange colored substance could be wiped off and what appeared to be rusted areas remained, and unable to be removed. The observation was confirmed by DM #216. -One full dome cover dispenser, sitting in the service line area next to the plate warmer revealed multiple food crumbs, dried food and dried liquid marks on both the inside and outside 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.
- Potential for harm · D2025-05-01 · 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
Based on medical record review, staff interview, review of the Electronic Information Dissemination and Collection (EIDC) system, and review of the facility policy, the facility failed to report an injury of unknown origin to the State Survey Agency (SSA). This affected one resident (Resident #7) of two residents reviewed for abuse. The facility census was 120. Findings include: Review of Resident #7's medical record revealed an admission date of 01/17/2011. Diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left non-dominant side, chronic kidney disease (CKD), epilepsy, chronic atrial fibrillation, mild cognitive impairment, and chronic pulmonary embolism. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/12/25, revealed Resident #7's cognition was unable to be assessed due to the resident being rarely/never understood. Further review revealed Resident #7 had impaired range of motion (ROM) on one side, utilized a wheelchair for mobility, was dependent on staff for personal hygiene and lower body dressing, and required…
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 · D2025-05-01 · 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
Based on medical record review, resident interview, staff interview and review of the facility policy, the facility failed to thoroughly investigate an injury of unknown origin. This affected one (#7) of two residents reviewed for abuse. The facility census was 120. Findings include: Review of Resident #7's medical record revealed an admission date of 01/17/2011. Diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left non-dominant side, chronic kidney disease (CKD), epilepsy, chronic atrial fibrillation, mild cognitive impairment, and chronic pulmonary embolism. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/12/25, revealed Resident #7's cognition was unable to be assessed due to the resident being rarely/never understood. Further review revealed Resident #7 had impaired range of motion (ROM) on one side, utilized a wheelchair for mobility, was dependent on staff for personal hygiene and lower body dressing, and required substantial/maximum staff assistance for upper body dressing. Review of the plan of care, revised…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and policy review the facility failed to ensure residents receive care consistent with professional standards of practice when they failed to timely transcribe a new physician order for a pressure ulcer dressing change for Resident #105. This affected one (Resident #105) of four Residents reviewed for pressure ulcers. The facility census was 120. Findings include: Record review of Resident #105 revealed an admission date of 11/08/24 with pertinent diagnoses of: sepsis, aphasia, type one diabetes mellitus, encephalopathy, cerebral infarction, chronic respiratory failure with hypoxia, hypertension, altered mental status, and personal history of other venous thrombosis and embolism. Review of the 02/17/25 quarterly Minimum Data Set (MDS) revealed Resident #105 is rarely or never understood and currently has a pressure ulcer. Review of the 04/23/25 wound assessment and care plan revealed the wound doctor came in and saw Resident #105 on the weekly wound rounds and wrote to change the order. The new order for left ischial tuberosity was to cleanse…
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 · D2025-05-01 · 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 record review, interviews, and facility policy review, the facility failed to timely respond to monthly medication regimen reviews (MRR) for two Residents (#51 and #76) out of five residents (#10, #51, #57, #76 and #89) reviewed for unnecessary medications. The facility census was 120. Findings include: 1. Review of the medical record revealed Resident #51 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, pneumonia, insomnia, bipolar and hypoxia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was severely cognitively impaired. Required one person assistance with activities of daily living and transport with a wheelchair. Review of the medication administration record (MAR) for November 2024 and December 2024 revealed Resident # 51 was receiving Trazadone 50 milligrams (mg) at bedtime. Review of the monthly medication regimen reviews revealed on 11/29/24 the pharmacist documented Resident #51 had been using Trazadone 50 mg 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.
- Potential for harm · Dcited before2025-05-01 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview and policy review, the facility failed to ensure accurate physician order reconciliation was conducted following a hospital admission for one (Resident #82) of two residents reviewed for hospitalizations. The facility census was 120. Findings include: Review of the medical record for Resident #82 revealed an admission date of 10/12/23 with diagnoses of end-stage renal disease, type II diabetes mellitus, occlusion and stenosis of an unspecified carotid artery, hypotension, and diastolic heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/04/25, revealed Resident #82 was cognitively intact and received dialysis. Review of the care plan dated 11/13/23 revealed Resident #82 had altered cardiovascular status related to atrial fibrillation, cerebrovascular accident (stroke), chronic kidney disease (CKD), hypotension, chronic heart failure, and peripheral vascular disease. Review of physician orders dated 11/27/24 revealed Resident #82 had an order for midodrine five milligram (mg) oral tablet every 12 hours as needed for low blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-01 · 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
Based on record review, observation, staff interview, and review of facility policy, the facility failed to ensure hand hygiene was performed prior to medication administration and failed to ensure proper sanitary practices were followed when preparing medications for administration. This failure affected one resident (Resident #82) out of the six residents observed during medication administration. The facility census was 120. Findings include: Review of the medical record for Resident #82 revealed an admission date of 02/17/25, with diagnoses including dysphagia, squamous cell carcinoma, and malignant neoplasm of the head, face, and neck. Review of the current physician orders identified the following medications were prescribed on 02/18/25: folic acid, 1 milligram (mg) tablet by mouth once a day, one multivitamin tablet by mouth, once daily, thiamine mononitrate 100 mg by mouth once daily, and Fluticasone propionate nasal suspension, 50 micrograms per activation twice daily. Observation of medication administration on 04/30/25 at 9:22 A.M. with Registered Nurse (RN) #201 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 · D2025-03-10 · 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
Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure resident dignity was maintained during medication administration. This affected one (Resident #93) of nine residents observed for dining. The facility census was 136 residents. Findings include: Review of the medical record for Resident #93 revealed an admission date of 11/27/24 with diagnoses including type two diabetes mellitus, dementia without behavioral disturbance, and anxiety. Review of the physician's orders for Resident #93 revealed an order dated 12/16/24 for Lispro insulin inject subcutaneously before meals for diabetes mellitus per sliding scale. Review of the Minimum Data Set (MDS) assessment for Resident #93 dated 01/16/25 revealed the resident was cognitively impaired. Observation of the lunch meal in the main dining room on 03/10/25 at 12:14 P.M. revealed Registered Nurse (RN) #164 checked Resident #93's blood sugar while the resident was eating lunch and without asking for the resident's consent. RN #93 then left the dining room and returned…
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 21 citations
- Potential for harm · Ecited before2025-02-06 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of facility policy, and staff interview, the facility failed to ensure the milk served during meal service remained in a safe and palatable temperature for serving. This had the potential to affect 56 residents (Residents #1, #2, #3, #5, #6, #8, #9, #10, #12, #13, #14, #15, #18, #19, #20, #21, #22, #23, #25, #27, #28, #32, #34, #35, #36, #37, #40, #41, #42, #43, #47, #48, #49, #51, #52, #54, #59, #60, #63, #69, #74, #75, #76, #81, #82, #84, #89, #93, #101, #102, #103, #113, #116, #120, #130 and #238) who regularly consume milk. The facility census was 133. Findings include: Observation of breakfast meal service on 01/28/25 at 8:29 A.M. revealed multiple residents trays had various types of milk on them, those milks included low fat milk, 2% milk and whole milk. Direct care staff removed a 2% milk from the cart to complete a test tray. The milk temperature was 60 degrees Fahrenheit (F). Interview on 01/28/25 at 8:31 A.M. with Certified Nursing Assistant (CNA) #350 confirmed the 2% milk was at 60 degrees F. CNA #350 stated she was unsure of the safe…
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 · D2024-04-09 · 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
Based on medical record review, resident and staff interview, and review of a self-reported incident, the facility failed to ensure residents received proper assistance with transfers and toileting per the plan of care. This affected one (#1) of three residents reviewed for accidents. The facility census was 132. Findings include: Review of Resident #1's medical record revealed an admission date of 03/08/24 with diagnoses included encounter for orthopedic aftercare (fractured right ankle), foot drop of the left foot, unsteadiness on feet, weakness, cerebral infarction, morbid obesity, chronic kidney disease, chronic pain syndrome, and chronic respiratory failure. The resident was discharged on 04/01/24. Review of Resident #1's admission Minimum Data Set (MDS) assessment, dated 03/12/24, revealed the resident had intact cognition. The assessment indicated the resident had no behaviors, including rejection of care. The resident required physical assistance and was dependent for sit-to-stand, chair/bed-to-chair transfers, and toilet transfers. The MDS assessment indicated the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-11 · 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 medical record review, staff interviews, and review of the facility policy, the facility failed to ensure a resident's pressure ulcer was assessed and monitored and the treatment to the pressure ulcer was administered as physician ordered. This affected one (Resident #100) of three residents reviewed for pressure ulcer care. The facility census was 135 Findings include: Review of the closed medical record for Resident #100 revealed an admission date of 02/15/24. Diagnoses included encephalopathy, lack of coordination, muscle weakness, dementia, chronic kidney disease, and sacrococcygeal Deep Tissue Injury (DTI) (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). The resident was discharged on 02/24/24 to the hospital. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had severe cognitive impairment.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-11 · 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, resident and staff interview, and review of the facility policy, the facility failed to ensure a resident received the physician ordered catheter care. This affected one (Resident #200) of two residents reviewed for urinary catheter care. The facility census was 135. Findings include: Review of the medical record for Resident #200 revealed an admission date of 02/15/24. Diagnoses included muscle weakness, urinary tract infection, neuromuscular dysfunction of bladder with urinary stoma, and ileostomy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had intact cognition. Review of Resident #200's physician orders revealed an order dated 02/16/24 for straight catheter kits for self-catheterization every shift. Review of Resident #200's Treatment Administration Record (TAR) from 02/16/24 to 02/29/24 revealed straight catheter kits for self-catheterization every shift was not documented as provided on the following five days: 02/20/24, 02/21/24,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-11 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, and review of the facility policy, the facility failed to ensure residents received the physician ordered care of their ostomy. This affected one (Resident #200) of two residents reviewed for ostomy care. The facility census was 135. Findings include: Review of the medical record for Resident #200 revealed an admission date of 02/15/24. Diagnoses included neuromuscular dysfunction of bladder with urinary stoma and ileostomy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had intact cognition. Review of Resident #200's physician orders revealed an order dated 02/16/24 to empty colostomy bag as needed every shift for colostomy care. Review of Resident #200's Treatment Administration Record (TAR) from 02/16/24 to 02/29/24 revealed empty colostomy bag as needed every shift for colostomy care was not documented as provided on the following four days: 02/20/24, 02/21/24, 02/22/24 and 02/23/24 for the 12-hour shift.…
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 · D2024-03-11 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, observation, and review of the facility policy, the facility failed to ensure residents received care and services for their intravenous catheter (IV). This affected one (Resident #200) of two residents reviewed for IV care. The facility census was 135. Findings include: Review of the medical record for Resident #200 revealed an admission date of 02/15/24. Diagnoses included hypotension, urinary tract infection, severe protein calorie malnutrition, depression, nd acute kidney failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had intact cognition. Review of Resident #200's physician orders revealed an order dated 02/23/24, ok to put in peripheral IV one time only for one day. Resident #200 physician orders was silent for care of the peripheral IV, including maintaining patience and function and dressing changes. Review of Resident #200's Medication Administration Record (MAR) for February 2024, 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 · Dcited before2024-03-11 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #200) of one resident reviewed for significant medication errors. The facility census was 135. Findings include: Review of the medical record for Resident #200 revealed an admission date of 02/15/24. Diagnoses included urinary tract infection. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Review of Resident #200's physician orders revealed an order dated 02/26/24 for Ceftriaxone sodium (antibiotic) injection two gram intramuscularly one time only for pneumonia. A physician order dated 02/27/24 for Ceftriaxone sodium (antibiotic) injection one gram intramuscularly one time a day for pneumonia for six days. Review of Resident #200's Medication Administration Record (MAR) for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to ensure two residents (#9 and #67), who were dependent on staff for personal hygiene was shaved. This affected two (Resident #9 and #67) of three residents reviewed for personal hygiene. The facility census was 130. Findings Include: 1. Review of the medical record for Resident #67 revealed an initial admission date of 03/27/23 with the latest readmission of 01/20/24 with the diagnoses including metabolic encephalopathy, pseudomonas, sepsis due to pseudomonas, acute and chronic respiratory failure, hydronephrosis, chronic obstructive pulmonary disease (COPD), paraplegia, neuromuscular dysfunction of bladder, paralytic syndromes, spinal stenosis of cervical region, hypertension, insomnia, benign prostatic hyperplasia, depression, chronic pain syndrome and neurogenic bowel. Review of the plan of care dated 11/29/23 revealed the resident had a self-care deficit related to weakness, decreased mobility, paralytic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-07 · 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 medical record review, observations, staff interview and policy review the facility failed to ensure bladder incontinence care was provided correctly. This affected one (#101) of two residents observed for incontinence care. The facility identified there were 73 residents who were incontinent and required assistance. The facility census was 128. Findings included: Review of Resident #101's medical record revealed an admission date of 08/09/21, with diagnosis of multiple sclerosis. Review quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was cognitively intact. His functional status was limited assistance for bed mobility, transfers, and toilet use. He was extensive assistance for eating. He was occasionally incontinent for bladder and always incontinent for bowel. Observation on 09/06/23 at 9:30 A.M. revealed State Tested Nursing Aide (STNA) #237 and two unidentified aides placed Resident #101 in a sit to stand lift to perform bladder incontinence care. STNA #237 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.
- Potential for harm · Dcited before2022-05-19 · 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, facility policy and procedure review and interview the facility failed to ensure Resident #4 and Resident #60, who required staff assistance with activities of daily living care received adequate and timely assistance with nail care to promote proper hygiene. This affected two residents (#4 and #60) of four residents reviewed for activities of daily living (ADL). Findings Include: 1. Review of Resident #4's medical record revealed an initial admission date of 06/22/21 with the latest readmission of 01/28/22 and diagnoses including cerebrovascular accident (CVA) with left sided weakness, dysphasia, chronic obstructive pulmonary disease (COPD), diabetes mellitus, bipolar disorder, borderline personality disorder, viral hepatitis B, gastrostomy, anemia, major depressive disorder, insomnia, liver disease, alcohol dependence, hypertension and emphysema. Review of the plan of care, dated 06/30/21 revealed the resident had a self-care deficit related to CVA with left sided weakness, impaired cognition, bipolar disorder and dysphasia. Interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-19 · 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
Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #8's suprapubic urinary catheter collection bag was placed properly to prevent infection and promote proper flow/drainage of urine. This affected one resident (#8) of one resident reviewed for urinary catheters. The facility identified four residents with indwelling urinary catheters. Findings Include: Review of Resident #8's medical record revealed an initial admission date of 08/29/19 with the latest readmission of 07/26/21 and diagnoses including acquired absence of left leg above the knee, chronic kidney disease, hydronephrosis, diabetes mellitus, anemia, hyperlipidemia, disorders of the bladder, urogenital implants, hypertension, gastroesophageal reflux disease, insomnia, systemic lupus, obstructive and reflux uropathy and dysphasia. Review of the plan of care, dated 06/08/21 revealed the resident had the potential for infection related to suprapubic catheter related to hydronephrosis, obstructive uropathy, spasms and overactive bladder. Interventions…
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 · E2019-07-18 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based observation, staff interview, and menu review the facility failed to follow the menu for residents who received a consistent carbohydrate diet, and renal diet. This had the potential to affected 23 (#5, #16, #29, #34, #40, #43, #50, #53, #56, #57, #60, #76, #82, #85, #89, #91, #97, #100, #409, #412, #414, #419, and #425) out of 116 residents residing in the facility and who receive consistent carbohydrate diets and/or renal diets Facility census was 116. Findings include: Review of lunch menu for 07/17/19 revealed pineapple was on the menu for residents on a consistent carbohydrate diet and renal diet. Observation of the lunch tray line on 07/17/19 at 11:35 A.M. revealed Dietary Aide #202 placed cake on the tray for Resident #50. At 11:40 A.M. Dietary Aide #202 placed cake on Resident #76's tray. Dietary Aide #202 stated she did not have pineapple to put on the trays. There were bowls of cut up melon on tray line. Registered Dietitian (RD) #500 confirmed the menu was not followed and confirmed Resident #50 and #76 were on a consistent carbohydrate diet and/or renal diet. 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 · Ecited before2019-07-18 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, the facility failed to ensure pans were stored dry. This had the potential to affect 111 of the 116 residents residing in the facility, all except Resident #18, #22, #87, #89, and #416 who were identified as not received meals from the facility kitchen. Facility census was 116. Findings include: Observation of the kitchen on 07/18/19 at 10:50 A.M. with Registered Dietitian (RD) #500 revealed 10 pans were being stored wet and/or soiled with food debris. At the time of the observation on 07/18/19 at 10:50 A.M., an interview with RD #500 confirmed there were in excess of pans 10 pans improperly stored. The facility confirmed this had the potential to affect 111 out of the 116 residents residing in the facility who receive their meals from the kitchen and that Resident #18, #22, #87, #89 and #416 do not receive their meals from the kitchen.
- Potential for harm · D2019-07-18 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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, staff and resident resident interview, and medical record review, the facility failed to honor resident's food choices. This affected two (#60 and #82) of six sampled residents reviewed for food concerns. Facility census was 116. Findings include: 1. Review of Resident #82's medical record revealed she was admitted on [DATE] with diagnoses that included; gastro-esophageal reflux disease, anxiety disorder, chronic pain syndrome, post-traumatic stress disorder, borderline personality disorder, and type two diabetes, Review of Resident #82's annual Minimum Data Set (MDS) dated [DATE] revealed her speech was clear, she understood, understand, and her cognition was intact. Review of Resident #82's July 2019 monthly physician orders revealed her diet was a consistent carbohydrate diet. Interview of Resident #82 on 07/15/19 at 11:12 A.M. revealed she did not get the food items, on her tray, that she requested. Resident #82 stated there was never an explanation of why her food requests were not…
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 · D2019-07-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview and facility policy, the facility failed to maintain signed physician orders for an advance directive. This affected one (#412) out of 24 residents reviewed for advanced directives. Facility census was 116. Findings include: Review of Resident #412's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include hypertensive chronic kidney disease, congestive heart failure, low back pain, diabetes, endocarditis, hyperkalemia, weakness, fall, major depressive disorder, and hyperlipidemia. During an interview on 07/16/19 at 06:49 A.M., Resident #412 revealed that she would like to be a Do Not Resuscitate-Arrest (DNRCC-A) and did not want any life-saving measures to be taken. Review of Resident #412's medical record revealed a handwritten note on the front of the chart that stated DNRCC-A. Further review of the medical record lacked evidence of a signed physician order for DNRCC-A. Review of the electronic record lacked…
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 · D2019-07-18 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 and review of facility policy, the facility failed to maintain resident rooms and equipment in a clean and homelike manner. This affected two (#412 and #71) out of 24 residents reviewed for a clean and homelike environment. Facility census was 116. Findings include: During an interview and subsequent observation on 07/15/19 at 11:17 A.M., Resident #412 revealed concerns that her closet doors were off the tracks, there were soiled bed linens and a soiled hospital gown lying on a sitting chair and her bedside table respectively, and there was an unidentifiable black substance that had been splattered on her ceiling since her admission. She stated she had mentioned the above to staff. All of the above were observed at that time. During an interview on 07/15/19 11:47 A.M., Unit Manager #266 verified the closet door was off the tracks and there were soiled bed linens and a soiled hospital gown lying on a sitting chair and bedside table respectively. Unit Manager #266 immediately bagged and removed the soiled linens and stated she would…
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 · D2019-07-18 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to incorporate recommendations from the pre-admission screening and resident review (PASRR) II into the care plan and submit a re-determination once the initial level II PASRR expired. This affected one (#28) of 24 residents reviewed for PASRR's. The census was 116. Findings include: Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include bipolar disorder, schizophrenia, anxiety, and major depressive disorder. Further review of Resident #28's record revealed he was determined to be a level II on his PASRR related to his psychiatric diagnoses. Review of the PASRR determination letter, dated [DATE], revealed Resident #28 was approved to remain in the facility for a specified period of 90 days. The determination stated that the approval was given to allow sufficient time to prepare a safe and orderly transition from the nursing facility to the community and 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 · Dcited before2019-07-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff and family interview, the facility failed to assist a resident who was dependent on care with their personal hygiene needs. This affected one (#87) out of 24 residents reviewed for ADL care. Facility census was 116. Findings include: Review of Resident #87's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include quadriplegia, contracture, anoxic brain damage, and acute respiratory failure with hypoxia. According to the the Minimum Data Set (MDS) assessment dated [DATE], Resident #87 was dependent on staff for all activities of daily living (ADL's). Further review of the record revealed Resident #87 had a legal guardian, her mother. Observations on 07/15/19 at 05:09 P.M., 07/16/19 at 12:54 P.M., 07/16/19 at 01:26 P.M., 07/16/19 at 03:20 P.M., 07/17/19 at 08:03 A.M., 07/17/19 09:27 A.M., 07/17/19 at 01:50 P.M., and 07/15/19 at 05:09 P.M. revealed long, dark facial hair to Resident #87's chin. During an interview on 07/16/19…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-07-18 · 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 medical record and resident and staff interview, the facility failed to ensure a resident who was incontinent received care and treatment to restore as much continence as possible. This affected one (#84) out of three sampled residents reviewed for continence. Facility census was 116. Findings include: Review of Resident #84's medical record revealed she was admitted on [DATE] with diagnoses that included: unspecified of cerebral infarction, expressive language disorder, facial weakness, obstructive sleep apnea, type two diabetes, pulmonary embolism, hypotension, dysphagia, and functional intestinal disorders. Review of Resident #84's quarterly Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #84 had clear speech, usually understood, usually understand, and her cognition was intact. Resident #84 did not reject care, she required extensive assistance of two staff for bed mobility, was dependent on two staff to transfer, and required extensive assistance of one staff to toilet.…
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 · D2019-07-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, staff interview and policy review, the facility failed to ensure residents with respiratory care needs were given adequate care when they failed to change oxygen tubing weekly. This affected one (#78) out of one resident reviewed for oxygen usage. The facility census was 116. Findings include: Record review of Resident #78 revealed an admission date of 05/24/19 and most recent admission date of 07/03/19 with pertinent diagnosis of: unspecified fall, shortness of breath, dyspnea, asthma, acute respiratory failure, heart disease, obstructive sleep apnea, and type 2 diabetes mellitus. Observation on 07/15/19 at 12:07 P.M. revealed Resident #78 in her room with oxygen is use. Further observation revealed the oxygen tubing was dated 06/29/19. Interview with Unit Manager #266 on 07/15/19 at 12:07 P.M. verified the date on the oxygen tubing and stated they were supposed to be changed weekly. Interview with the Director of Nursing (DON) on 07/18/19 at 11:41 A.M. revealed that the facility policy stated to change oxygen tubing routinely and that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-07-18 · 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 review of facility policy, the facility failed to keep a treatment cart on 100 hall locked. This affected one (#87) of 24 residents who were reviewed for ensuring all biologicals were kept in locked compartments. The census was 116. Findings include: Observation on 07/16/19 at 1:02 P.M. revealed a treatment cart that was unlocked on the 100 hall. The treatment cart contained biologicals including: 30 bacitracin zinc ointment tubes, which read, keep out of reach of children, one tube of pansement hydrophile which read, keep out of reach of children, eight tubes of diflonec sodium topical gel 1%, a topical anti-inflammatory prescribed to Resident #87 that read, keep out of reach of children. During an interview on 07/16/19 at 1:04 P.M., Registered Nurse (RN) #42 verified the treatment cart was unlocked and that 30 bacitracin zinc ointment tubes, one tube of pansement hydrophile, eight tubes of diflonec sodium topical gel 1%, a topical anti-inflammatory prescribed to Resident #87, were accessible to others who did not have authorized access 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$168,656 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $168,656 — penalty dated 2025-02-06
- Medicare payment denial — starting 2024-03-08 for 36 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 OPTALIS HEALTH & REHABILITATION — 36 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 | 3 of 5 | 2.4 | +0.6 vs chain |
| Health inspection | 2 of 5 | 1.9 | +0.1 vs chain |
| Staffing | 3 of 5 | 2.4 | +0.6 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 35 homes this chain runs (chain average 2.4★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| OM HOLDCO 2 LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 06/01/2022 |
| OPTALIS LP INVESTORS 2 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 06/01/2022 |
| SNW LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 30% | since 06/01/2022 |
| OPTUM MANAGEMENT SOLUTIONS. INC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 06/01/2022 |
| ZIMMERMAN, ADAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/28/2026 |
| CHARLES FRANKLIN LLC | Organization | ADP OF THE SNF | — | since 06/01/2022 |
| CHARLES WESTLAND LLC | Organization | ADP OF THE SNF | — | since 06/01/2022 |
| CLIFTONLARSONALLEN LLP | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| FORBRIGHT BANK | Organization | ADP OF THE SNF | — | since 02/16/2026 |
| HEMANT SHAH 2018 IRREVOCABLE TRUST | Organization | ADP OF THE SNF | — | since 06/01/2022 |
| PAAR 108 LLC | Organization | ADP OF THE SNF | — | since 06/01/2022 |
| PINAL R. PATEL 2017 IRREVOCABLE TRUST F/B/O AARNA R. PATEL | Organization | ADP OF THE SNF | — | since 06/01/2022 |
| PINAL R. PATEL 2017 IRREVOCABLE TRUST F/B/O ANSH R. PATEL | Organization | ADP OF THE SNF | — | since 06/01/2022 |
| PINAL R. PATEL 2020 IRREVOCABLE FAMILY TRUST UAD 10-6-2020 | Organization | ADP OF THE SNF | — | since 06/01/2022 |
| RAJAN G PATEL 2020 IRR FAM TR UAD 12-3-2020 | Organization | ADP OF THE SNF | — | since 06/01/2022 |
| SCHLAUPITZ MADHAVAN | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| RATNARAJAH, GOKULAN | Individual | ADP OF THE SNF | — | since 01/28/2026 |
CMS files one row per role, so the 21 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.
15 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $693K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 365272. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-01, 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.