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Willow Brook Christian Home

55 Lazelle Rd, Columbus, OH 43235 · Non profit - Corporation · 50 certified beds · (614) 885-3300 Medicare & Medicaid certified

Call the home — (614) 885-3300 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0609, F0610) — most recent Dec 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — 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

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
8351 N High St Ste 155 · (614) 664-3595 · Call to confirm hours
Pharmacy
7654 Crosswoods Dr · (614) 847-6007 · Call to confirm hours
Grocery
58 Dillmont Dr · (614) 360-2174 · Call to confirm hours
Park
9466 N High St · Typically dawn to dusk
Place of worship
60 Dillmont Dr · (614) 314-8396

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 improved from 3 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.6%5.3%15.4%worse than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight6.7%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 infection0.7%0.4%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms21.3%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 injury3.4%3.2%3.3%typical
Long-stay residents whose ability to walk worsened7.8%6.1%16.1%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication10.8%25.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers2.7%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control27.0%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table1.9%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 vaccine85.7%75.6%79.4%typical
Short-stay residents rehospitalized after admission13.9%24.9%22.6%better
Short-stay residents with an outpatient ER visit8.1%12.9%12.0%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.

56.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 88 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.7%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
67.4%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 67.4% 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 46 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% 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 SNF56.7%CMS range 49.1–63.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.6–15.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge67.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge65.2%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 discharge41.3%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 identified98.1%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 discharge86.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.4%CMS range 4.0–12.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.921.02Oct 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

1.37
RN hours/ resident / day
0.16
LPN hours/ resident / day
2.49
Aide hours/ resident / day
4.03
Total nurse hours/ resident / day
0.89
RN hoursweekends
38.9%
Total nursing turnover
14.3%
RN turnover

How full it usually is: this home is certified for 50 beds and averages 43.7 residents a day — about 87% occupied, or roughly 6 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 4.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.37 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 3.54 hrs/resident/day on weekends vs 4.22 on weekdays — 16% thinner on weekends. RN hours go from 1.57 to 0.89 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

4
deficiencies at the latest standard inspection (2026-04-30)
12
at the previous standard inspection (2024-11-07)

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

Inspection deficiencies

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

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · Gcited before2025-09-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, hospital record review, interview, observation, review of the mechanical lift instructions, and policy review, the facility failed to use appropriate slings for the mechanical lift and failed to maintain the mechanical lift per the manufacturer's instructions resulting in significant resident injury with mechanical lift transfers. Actual harm occurred on 07/20/25 when Resident #4, who required extensive assistance from two staff members and a mechanical lift with transfers, experienced a fall during a mechanical lift transfer when staff used the incorrect sling and the sling straps broke. The resident was transferred to the emergency room for evaluation and subsequently admitted to the surgical trauma intensive care unit overnight due to multiple rib fractures and a right occipital scalp contusion and hematoma. Additionally, an incident of actual harm occurred on 07/18/25 when Resident #1, who required extensive assistance from two staff members and the use of a mechanical lift…

    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 · Fcited before2026-04-30 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the Legionella plan, policy review and staff interview, the facility failed to ensure the Legionella plan parameters for temperature readings were followed and failed to ensure new interventions were initiated for documented temperatures readings below the control measure. This had the potential to affect all facility residents. The facility census was 49. Findings include: Review of the Legionella plan dated 07/2025 revealed the facility shall check the outflow and return temperatures of the domestic water heaters. The domestic water heaters had control temperatures of 118 degrees Fahrenheit (F) for the county water and 140 degrees F for the city water. Review of the 2026 monthly temperature logs revealed the county water heater temperature readings were below the control measure. For January the temperatures were 110 degrees F and 112 degrees F; February's were 113 degrees F and 115 degrees F; March's were 110 degrees F and 111 degrees F; and April's were 116 degrees F and 118 degrees F. The city water temperature readings below the control measures for January…

    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 · D2026-04-30 · 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, interview, and review of facility policy, the facility failed to ensure the comprehensive care plan was updated for a fall intervention for Resident #45. This affected one resident (#45) of three residents reviewed for falls. The facility census was 49.Findings Include: Review of Resident #45's medical record revealed she was admitted on [DATE] with diagnoses that included but were not limited to hypertension, insomnia and dementia.Review of facility investigation report dated 01/16/26 revealed Resident #45 was found on the floor mat directly beside her bed and a silent bed alarm was implemented as the immediate action taken for fall. Review of Resident #45's progress notes dated 01/20/26, revealed an interdisciplinary team (IDT) note for the fall on 01/16/26 stating a silent alarm was to be applied when Resident #45's was in bed and the plan of care (POC) was reviewed and updated. Review of Resident #45's physicians orders dated revealed an order dated 01/16/26 for a silent alarm…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, review of the medical record, and review of facility policy, the facility failed to ensure baseline weight measurements were obtained and verified in a timely manner after admission. This affected one resident (#7) of one resident reviewed for nutrition and weight loss. The facility census was 49.Findings include:Review of the medical record for Resident #7 revealed the resident was admitted to the facility on [DATE] with diagnoses that included unspecified dementia and hypertension amongst other diagnoses, with the diagnosis unspecified protein-calorie malnutrition added to the medical record on 01/29/26. Further review of the resident's medical record revealed the resident's cognition could not be assessed using a standardized cognition assessment tool due to the resident being rarely or never understood, though the resident's cognitive skills for daily decision making were noted to be impaired.Review of weight measurements found in Resident #7's medical record revealed an initial…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-30 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, interviews, review of Food and Drug Administration (FDA) guidance, and policy review, the facility failed to ensure residents drug regimen was free from unnecessary drugs when pain medication parameters were not in place. This affected two residents (#12 and #24) out of three residents reviewed for pain. The facility census was 49. Findings include:1. Review of the medical record for Resident #12 revealed an admission date of 04/10/26. Diagnoses included absence of right leg below the knee, encephalopathy, dysphagia, kidney disease, atrial fibrillation, heart failure, hypertension, edema, and Parkinson's disease.Review of physician orders dated 04/10/26 revealed orders for acetaminophen oral tablet 325 milligrams (mg) with instructions to give three tablets every eight hours for pain.Review of physician orders dated 04/10/26 revealed orders for acetaminophen oral tablet 325 mg with instructions to give one tablet every six hours as needed for mild pain.Review of the plan 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-23 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the self-reported incidents and policy review, the facility failed to ensure an injury of unknown origin was timely reported to the state agency. This affected one (#44) of three residents reviewed who had injuries. The facility census was 40. Findings include Based on medical record review, staff interview, review of the self-reported incidents and policy review, the facility failed to ensure an injury of unknown origin was timely reported to the state agency. This affected one (#44) of three residents reviewed who had injuries. The facility census was 40. Findings Include:Review of the medical record for Resident #44 revealed an admission date of 02/01/22 and death/discharge date of 09/11/25. Diagnoses included vitamin D and B12 deficiencies, dementia with behavioral disturbance, malnutrition and Alzheimer's disease late onset.Review of the care plan dated 02/01/22 revealed Resident #44 had the potential for skin impairment related to fragile skin 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-23 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the self-reported incidents and policy review, the facility failed to timely investigate an injury of unknown origin. This affected one (#44) of three residents reviewed for injuries. The facility census was 40. Findings include Based on medical record review, staff interview, review of the self-reported incidents and policy review, the facility failed to timely investigate an injury of unknown origin. This affected one (#44) of three residents reviewed for injuries. The facility census was 40. Findings include:Review of the medical record for Resident #44 revealed an admission date of 02/01/22 and death/discharge date of 09/11/25. Diagnoses included vitamin D and B12 deficiencies, dementia with behavioral disturbance, malnutrition and Alzheimer's disease late onset.Review of the care plan dated 02/01/22 revealed Resident #44 had the potential for skin impairment related to fragile skin and decreased mobility with interventions to wear geri-sleeves 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-07 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of facility policy, the facility failed to develop comprehensive care plans for Resident #10, #12, #15, #34, and #41. This affected five residents (#10, #12, #15, #34, and #41) of 18 records reviewed for care planning. The facility census was 45. Findings include: 1. Review of Resident #34's medical record revealed an admission date of 08/18/20 with diagnoses including major depressive disorder, anxiety disorder, Parkinson's disease, occipital neuralgia, and spondylosis without myelopathy. Review of Resident #34's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had a moderate cognitive impairment. Review of Resident #34's physician order dated 06/05/24 revealed an order for Clonazepam (benzodiazepine) 0.5 milligrams (mg) one tablet by mouth for anxiety. Review of Resident #34's physician order dated 09/01/24 revealed an order for Sertraline (antidepressant) tablet 75 mg by mouth one time a day for depression and anxiety. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interviews, and resident interviews, the facility failed to ensure all residents received dignified choices to remain in their room. This affected one (Resident #300) out of one resident reviewed for dignity. The facility census was 45. Findings include: Review of the medical record for Resident #300 revealed an admission date of 10/15/24 and diagnoses of hypertension, hyperlipidemia, hypothyroidism, chronic pain syndrome, anxiety disorder, primary insomnia, depression, polyneuropathy, tachycardia, urinary tract infection (UTI), and encephalopathy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #300 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Resident #300 had no behavioral problems. Review of the care plan for Resident #300 revealed a goal that the resident will be free of falls. The intervention stated, personal alarm when in bed or chair at all times.…

    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 · D2024-11-07 · 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

    Based on observation, staff interviews, and resident interviews, the facility failed to provide a comfortable, homelike environment for Resident #35. This affected one resident (#35) of six residents reviewed for comfortable living spaces. The facility census was 45. Findings Include: Resident #35 had an admission date of 12/08/20 with diagnoses including retention of urine, hypertension, neuromuscular dysfunction of bladder, age related osteoporosis with current pathological fracture of vertebrae, assistance with personal care, muscle weakness, abnormalities of gait and mobility, insomnia, urinary tract infection, and anxiety disorder. Observations on 11/04/24, 11/05/24, and 11/06/24 revealed a minimum of 11, and a maximum of 12 packages of incontinence briefs stacked and stored along the wall in Resident #35's bathroom. Some packages were opened with briefs scattered randomly about the space on the floor and on top of the unopened packages creating a disorderly, and uncomfortable living space for Resident #35. Interview with Resident #35 on 11/04/24 at 9:52 A.M. confirmed that she…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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, resident and staff interview, and record review, the facility failed to document ongoing assessments to evaluate the need for the use of physical restraints. This affected two residents (#28 and #300) of eight residents reviewed for the use of restraints. The facility census was 45. Findings include: 1. Resident #28 had an admission date of 11/27/19 with diagnoses including major depressive disorder, cardiac arrhythmia, hypertension, overactive bladder, gastroesophageal reflux disease (GERD), diverticulosis, cognitive communication deficit, and dementia. Review of the care plan dated 11/09/22 for Resident #28 on 11/07/24 at 12:53 P.M. revealed that Resident #28 was a high risk for fall, and had an intervention listed to place a personal alarm to wheelchair and recliner every shift. Review of the medical record for Resident #28 on 11/07/24 at 11:02 A.M. revealed no initial assessment, nor ongoing assessments for the use of alarm devices and/or restraints. Review of the medical record 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2024-11-07 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, resident family interview, staff interview, and facility policy review, the facility failed to provide the resident or resident representative with a written notice of a bed hold. This affected one (Resident #25) out of two residents reviewed for hospital transfers. The facility census was 45. Findings include: Review of the medical record for Resident #25 revealed an admission date of 09/27/24 with diagnoses of dementia, chronic kidney disease, type two diabetes mellitus, parkinsonism, hypertension and muscle weakness. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed 10/09/24 revealed Resident #25 was moderately cognitively impaired, exhibited no behaviors, and required partial/moderate assistance with toileting and bathing. The resident required substantial/maximal assistance with bed mobility. Review of progress notes dated 10/09/24 revealed Resident #25's wife shared concerns about finances and the resident's long-term stay. She noted that while they had long-term care insurance, it only covered $100 per day, and she was worried…

    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 · Dcited before2024-11-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to ensure Resident #34's dressing changes for a skin tear were completed as ordered. This affected one resident (#34) of two residents reviewed for skin conditions. The facility census was 45. Findings include: Review of Resident #34's medical record revealed an admission date of 08/18/20 with diagnoses including major depressive disorder, anxiety disorder, Parkinson's disease, occipital neuralgia, and spondylosis without myelopathy. Review of Resident #34's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had moderate cognitive impairment. Review of Resident #34's progress note dated 10/26/24 revealed she had a fall and obtained an 'area on the left hand.' She was sent to the hospital due to a different injury. Review of Resident #34's fall investigation dated 10/26/24 revealed she had a fall and received first aide, there was a dressing on the left hand. Review of Resident #34's progress note…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and record review the facility failed to ensure the resident environment remained free of accident hazards by safely storing portable oxygen per the facility policy/procedure. This had the potential to affect one (Residents #38) of one resident reviewed. The facility census was 45. Findings include: Observation on 11/04/24 at 9:22 A.M. revealed three portable oxygen tanks stored in Resident #38's room. Two of the tanks were stored using a transport cart, one tank was freestanding and unsecured, leaning against the wall. Interview with Certified Nursing Assistant (CNA) #157 confirmed the oxygen tanks stored in Resident #38's room were not currently in use, and the one oxygen tank that was freestanding and unsecured, should be on a cart. CNA #157 confirmed the three oxygen tanks should be returned to the designated oxygen storage room. Review of the facility's policy titled, Oxygen Safety dated 02/18/22, and revised on 02/18/24, on revealed the facility's policy was to provide a safe environment for residents, staff, and the public. Compliance guideline number…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to document nutritional supplement intake and complete an annual nutrition assessment. This affected three (Resident #25, #36 and #41) of eleven reviewed for the use of nutritional supplements. The facility census was 45. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 09/27/24 with diagnoses of acute kidney failure, dementia, type two diabetes mellitus, protein calorie malnutrition and parkinsonism. Review of the Minimum Data Set (MDS) assessment completed 10/09/24 revealed Resident #25 was moderately cognitively impaired and required setup or clean-up assistance with eating. Review of weight summary dated 09/25/24 revealed Resident #25 weighed 200 pounds, and on 11/01/24, Resident #25 weighed 189 pounds, reflecting a 5.5% weight loss over a two-month period. Review of Nutrition - Fluids plan of care response history revealed no documented fluid intakes from 10/07/24-11/07/24 for Resident #25. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-07 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to follow ordered medication administration parameters, and failed monitor a resident for side effects of anticoagulant use. This affected two (Resident #33 and Resident #25) of six resident reviewed for medications. The facility census was 45. Findings include: 1. Review of the medical record for Resident #33 revealed an admission date of 09/09/24 with diagnoses of pseudomonas, muscle weakness, type II diabetes, anxiety disorder, paroxysmal atrial fibrillation, hypertension, hyperlipidemia, primary osteoarthritis, glaucoma, protein calorie malnutrition, and urinary tract infection (UTI). Review of the Minimum Data Set (MDS) assessment completed 09/27/24 revealed a Brief Interview for Mental Status (BIMS) score of nine indicating the resident had cognitive impairment with no behavioral problems in place. Review of Resident #33's care plan dated 09/09/24 revealed the resident had hypertension and atrial fibrillation and will remain free of complications. Interventions included give anti-hypertensive medications as…

    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 · D2024-11-07 · 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 adequately identify and monitor targeted behaviors for residents who use psychotropic medications. This affected one (Resident #15) of five residents reviewed for unnecessary medications. The census was 45. Findings include: Resident #15 was admitted to the facility on [DATE]. Her diagnoses were atrial fibrillation, pain in shoulder, rhabdomyolysis, lymphedema, hypertension., hyperlipidemia, candidiasis, and heart failure. Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Review of Resident #15's current physician orders found she was prescribed Zoloft (anti-depressant) 25 milligrams (mg) at bedtime for depression. This ordered was started in June 2024. Review of Resident #15's current care plan revealed no care plan to identify the use of Zoloft, nor any interventions or documentation to identify targeted behaviors for the use of an anti-depressant. Review of Resident #15's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-07 · 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

    Based on observation, staff interview, and record review, the facility failed to remove, inactivate, or destroy pathogenic organisms on the surface of a multi-use device (glucometer) to the point where it was rendered safe for handling and re-use. This had the potential to affect three residents (#9, #297, #25) receiving glucometer checks on the Skilled Unit. The census was 45. Findings include: Observation on 11/06/24 at 11:46 A.M. of Registered Nurse (RN) #117 completing a finger stick blood glucose stick (FSBS) on Resident #297 revealed prior to going into the resident room, RN #117 swiped the top of the glucometer with a sani wipe, and then entered Resident #297's room, placed the glucometer on the over bed table without placing a barrier on the table, performed the FSBS check, exited the room after performing hand hygiene and then placed the glucometer on top of the medication cart without the use of a barrier. RN #117 then documented the FSBS in the electronic health record and placed the glucometer in the top drawer of the medication cart without cleansing or sanitizing 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · 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

    Based on record review and interview the facility failed to follow guidance within their antibiotic stewardship program to ensure antibiotics were ordered appropriately. This affected two (Resident #33 and #101) out of three reviewed for appropriate antibiotic usage. The facility census was 45. Findings include: 1. Review of the medical record for Resident #101 revealed an admission date of 09/06/24 with diagnoses of spinal stenosis, Crohn's disease, anxiety, urinary tract infection, osteoporosis and anemia. Review of Minimum Data Set (MDS) 3.0 assessment completed 09/13/24 revealed Resident #101 was cognitively intact, required substantial to maximal assistance with toileting, and was occasionally incontinent of urine. Review of hospital records dated 09/06/24 revealed Resident #101 was admitted for elective decompression and fusion of the L3-L5 vertebrae. Complications during the hospital stay included acute-on-chronic anemia and a urinary tract infection (UTI) (possibly present on admission). It was noted the UTI was suspected to have developed during the hospital stay, although…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-02-28 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and policy review, the facility failed to implement Legionella prevention plan according to the facility water management plan. This had the potential to affect 44 of 44 residents in the facility. Facility census was 44. Findings include: Review of the Legionella maintenance plan revealed weekly maintenance plans included weekly water temperature logs of cold water systems, hot water systems, hot water boilers and hot water tanks. The maintenance plan revealed weekly visual inspection of the spa tubs. The maintenance plan revealed monthly visual inspections to be completed of the showerheads and aerators and quarterly plans for visual inspections of the ice machines, water dispensers, and drinking fountains. Interview on 02/24/22 at 9:00 A.M., with Maintenance Director (MD) #188 revealed when a room is vacant for over two weeks, or water source goes unused, the pipes will be flushed for at least five minutes prior to their next use. MD #188 revealed the water drinking fountains were closed during the COVID outbreak and have reopened. MD #188…

    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 · Ecited before2022-02-28 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident interview, staff interview, family interview, and policy review, the facility failed to monitor resident's skin impairments and edema. This affected four (#6, #9, #13, and #40) of four residents reviewed for skin impairments. The census was 44. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 11/22/21 and the diagnoses of elevated liver enzymes, chronic obstructive pulmonary disease, volvulus, syncope and collapse, encephalopathy, and bipolar disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required limited assistance of one staff for bed mobility, extensive assistance of one staff for transfers, locomotion, toilet use and personal hygiene. Review of the care plan dated 12/08/21 revealed Resident #9 had an activities of daily living (ADL) self-care performance deficit related to weakness, syncope, demyelating disease and diarrhea with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-28 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, self-reported incident review and facility policy review, the facility failed to timely notify the Administrator and state agency (Ohio Department of Health (ODH) of an alleged incident of abuse/neglect. This affected one (#9) of one resident reviewed for abuse. The census was 44. Findings include: Review of the medical record for Resident #9 revealed an admission date of 11/22/21, with the diagnoses of elevated liver enzymes, chronic obstructive pulmonary disease, syncope and collapse, encephalopathy, and bipolar disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required limited assistance of one staff for bed mobility, extensive assistance of one staff for transfers, locomotion, toilet use and personal hygiene. It also stated the resident had no behaviors. Review of the care plan dated 12/08/21 revealed the resident had bowel incontinence with interventions 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 · D2022-02-28 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to accurately reflect resident wounds. This affected two (#19 and #32) of three reviewed for resident assessments. The facility census was 44. Findings include: 1. Review of the medical record revealed Resident #32 revealed an admission on [DATE], with diagnoses including hypertension, hyperlipidemia, peripheral vascular disease, major depressive disorder, gastro-esophageal reflux disease without esophagitis, type two diabetes mellitus, and personal history of other venous thrombosis and embolism. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #32 had intact cognition. Review of the assessment revealed Resident #32 did not have any unhealed pressure ulcers or injuries. Resident #32 was identified as having a diabetic foot ulcer. Review of the wound note dated 01/10/22 for Resident #32 revealed she did not have a diabetic foot ulcer. Resident #32 was listed as having a stage two pressure ulcer…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-28 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 complete a Preadmission Screening and Resident Review (PASARR) for a resident. This affected one (#19) of one resident reviewed for PASARR. The facility census was 44. Findings include: Review of the medical record revealed Resident #19 revealed an admission of 12/16/21, with diagnoses including type two diabetes mellitus, personal history of pulmonary embolism, bipolar disorder, dysphagia, other schizoaffective disorder, major depressive disorder, anemia, and metabolic encephalopathy. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had intact cognition. Review of the medical record for Resident #19 on 02/22/22 at 11:00 A.M., revealed no evidence a Preadmission Screening and Resident Review (PASARR) had been completed following admission. Review of the PASARR dated 02/22/22 revealed the assessment was completed due to an expiring hospital exemption. Interview on 02/23/22 at 11:22 A.M., with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-28 · 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, medical record review, staff interview and policy review, the facility failed to ensure a medication error rate of less than 5 percent (%). There were three medication errors out of 33 opportunities to equal an error rate of 9.09%. This affected three (#4, #6, and #7) of eight residents observed during the medication administration observation. The census was 44. Findings Include: 1. Review of the medical record for Resident #4 revealed an admission date of 01/28/12 and the diagnoses of high blood pressure, diabetes type two, fatigue, and heart failure. Review of the monthly physician orders for February 2022 revealed the resident was ordered a stool softener-laxative twice daily for constipation and the order stated in bright red letters Dose check not performed. There was no medication specified and no dosage specified. Observation on 02/22/22 at 3:16 P.M. with Registered Nurse (RN) #117 revealed she administered Senna Plus 8.6-50 milligrams (mg) to Resident #4. Interview on 02/23/22 at 3:37 P.M., with RN #117 confirmed the residents stool softener-laxative…

    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

“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.

Who owns this facility

Owner / managerTypeRoleSince
BARTH, PHILIndividualCORPORATE DIRECTORsince 08/16/2004
DAVIS, BRANDIIndividualCORPORATE DIRECTORsince 01/11/2024
IRWIN, TERRYIndividualCORPORATE DIRECTORsince 01/01/2005
JOHNSON, WILLIAMIndividualCORPORATE DIRECTORsince 11/14/2019
LONGO, SCOTTIndividualCORPORATE DIRECTORsince 03/10/2007
MAY, JERRYIndividualCORPORATE DIRECTORsince 07/24/2025
MCKENNA, BLYTHEIndividualCORPORATE DIRECTORsince 01/23/2025
PICKENS, ROGERIndividualCORPORATE DIRECTORsince 11/08/2012
RINGLE, MICHAELIndividualCORPORATE DIRECTORsince 04/26/2025
SARKEL, EDIndividualCORPORATE DIRECTORsince 05/09/2019
SUSENNA, KARENIndividualCORPORATE DIRECTORsince 11/09/2017
TIDWELL, PEGGYIndividualCORPORATE DIRECTORsince 03/16/2013
MCKNIGHT, MATTHEWIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/09/2023
POULSON, THOMASIndividualCORPORATE OFFICER; ADP OF THE SNFsince 06/28/2010
HARRIS, KENTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/10/2025
KETRON, NICOLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2005
RICHARD, NEILIndividualADP OF THE SNFsince 03/01/2016

CMS files one row per role, so the 22 rows in the source record cover these 17 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
-29.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 10%Medicare 8%Other / private 82%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$376per resident / day
operating cost
$11,432per month
≈ monthly operating cost
$291per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365988. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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