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Lake Pointe Rehabilitation And Nursing Center

22 Parrish Road, Conneaut, OH 44030 · For profit - Corporation · 74 certified beds · (440) 593-6266 Medicare & Medicaid certified

Call the home — (440) 593-6266 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jun 2024Resident-funds citation (F0570)
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
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0570)
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (63%) runs well above the national median (45%)

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
158 W Main Rd · (440) 593-0356 · Call to confirm hours
Pharmacy
380 State St · (440) 593-6214 · Call to confirm hours
Grocery
927 Main St · (440) 599-2020 · Call to confirm hours
Park
65 Parrish Rd · (440) 599-1730 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5

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 1 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.

Overall rating3★
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 increased2.7%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight3.2%6.2%5.4%better
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 infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms81.5%30.1%6.5%worse 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 injury2.4%3.2%3.3%better
Long-stay residents whose ability to walk worsened0.0%6.1%16.1%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication31.9%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers1.6%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control20.6%21.4%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table9.7%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 vaccine95.7%75.6%79.4%better
Long-stay hospitalizations per 1,000 resident days1.871.731.67worse
Long-stay outpatient ER visits per 1,000 resident days6.681.801.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

47.4% 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 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.4%U.S. median 51.5%
Got home and stayed home
11.8%U.S. median 10.7%
Went back to hospital
not reportedno hours filed
Therapy hours / resident / day

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 SNF47.4%CMS range 35.6–62.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.8%CMS range 8.1–16.010.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.0%CMS range 3.9–15.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.491.02Oct 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

0.39
RN hours/ resident / day
0.73
LPN hours/ resident / day
1.83
Aide hours/ resident / day
2.95
Total nurse hours/ resident / day
0.27
RN hoursweekends
63.2%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 74 beds and averages 56.9 residents a day — about 77% occupied, or roughly 17 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 2.95 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.71 hrs/resident/day on weekends vs 3.05 on weekdays — 11% thinner on weekends. RN hours go from 0.44 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% is well above 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

6
deficiencies at the latest standard inspection (2026-01-06)
3
at the previous standard inspection (2023-11-08)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · Fcited before2026-01-06 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, and review of the dietitian contract, the dietetic technician's personnel file, and emails, the facility failed to ensure dietitian oversight of a dietetic technician's competency. This had the potential to affect all residents residing in the facility. The facility census was 61.Findings include:Review of the contract between the facility and Consultant Registered Dietitian (CRD) #249 dated 08/01/25 revealed the said dietitian provided the facility with medical nutrition therapy for its residents to include but not limited to nutrition assessments based on the minimum data set (MDS) schedule, and assessments of residents experiencing significant weight changes, compromised skin integrity (pressure ulcers specifically), or has a high risk with receiving specialized care, such as dialysis, tube feeding or hospice services and pediatrics as needed. The primary clinical duties were carried out by the Dietetic Technician (DT), which CRD #249 would supervise. The CRD visited the facility quarterly and more often as needed to complete food service operations audits,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-01-06 · tag F0842 — failed to keep accurate, complete medical records — widespread
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and facility policy review, the facility failed to maintain resident medical records in a secure environment that safeguarded it from unauthorized use and prevented loss or destruction. This affected an unidentified number of discharged residents. The facility census was 61.Findings include:Interview on 12/30/25 at 12:30 P.M. with Director of Nursing (DON) regarding storage of resident medical records revealed storage of any current residents' records were kept in the locked business office area for confidentiality but stated being unsure of where discharged residents' records were kept.Observation on 12/30/25 at 12:55 P.M. of a detached storage garage on the facility grounds with Director of Maintenance (DOM) #210 revealed it was an unlocked storage area which contained general storage of maintenance equipment and a large amount of banker boxes filled with files. Near the entrance of the garage door were approximately ten opened and unsealed boxes piled on top of each other which contained confidential medical and personal information of discharged…

    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 · E2026-01-06 · tag F0570 — pattern
    Assure the security of all personal funds of residents deposited with the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, review of the facility surety bond, review of the resident fund balance, and review of a facility email review, the facility failed to maintain surety bond coverage to meet or exceed the total resident fund balance. This affected 29 residents (#1, #2, #3, #6, #9, #12, #14, #16, #20, #25, #27, #28, #29, #31, #32, #33, #35, #38, #39, #41, #44, #45, #47, #48, #51, #52, #53, #56 and #59) out of 29 residents reviewed for resident funds. The facility census was 61.Findings include:Review of the facility document labeled Trust Current Account Balance as of 01/05/26, the total resident fund balance for Residents #1, #2, #3, #6, #9, #12, #14, #16, #20, #25, #27, #28, #29, #31, #32, #33, #35, #38, #39, #41, #44, #45, #47, #48, #51, #52, #53, #56 and #59 was $24,725.31. Review of the facility's surety bond signed 10/24/24 and effective for effective from 02/01/25 through 02/01/26 revealed a coverage amount of $15,000.00, which is less than the total resident fund balance.Review of a facility email dated 01/06/26 at 8:38 A.M. revealed a request by the Chief Financial…

    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 · E2026-01-06 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and facility policy, the facility failed to ensure residents had a clean, comfortable, and homelike environment. This affected five Residents (#15, #19, #24, #25 and #41) out of five residents reviewed for environment. The facility census was 61.Findings include:1. Observation on 12/29/25 at 10:00 A.M. with Maintenance Director (MD) #210 of Residents #24 and #25's room revealed packaging tape wrapped around the window curtains over the window. A strong draft of cold air was felt leaking around the closed curtains. The bathroom had stained and dirty flooring as well as a black substance around the faucet fixtures. The bathroom door had a large piece of wood missing and the door edges were uneven and rough having potential for splintering. The air pressure alarm for Resident #25's mattress was alarming. Interview at the time of the observation with Residents #24 and #25 and MD #210 revealed the residents complained to MD #210 regarding the draft of cold air leaking from the window. MD #210 provided Resident #25 with wide packaging tape to seal 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-06 · tag F0656 — failed to write and follow a full care plan — isolated
    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 interviews, medical records and facility policy, the facility failed to ensure care plans reflected resident needs regarding diagnoses and medications. This affected one Resident (#4) out of eight resident records reviewed. The facility census was 61.Review of medical record for Resident #4 revealed an admission date of 11/04/25 with a diagnoses of cellulitis left lower limb, septic pulmonary embolism, methicillin resistant staphylococcus aureus, staphylococcal arthritis left ankle and foot, neuromuscular dysfunction of bladder, and iron deficiency anemia. Review of comprehensive care plan dated 11/04/25 revealed no goals or interventions to manage Resident #4's foley catheter which was present on admission, or was revised to include diagnosis of anemia and hypokalemia (low potassium) which required a blood transfusion and intravenous potassium chloride infusion at the hospital on [DATE]. Resident labs are now being monitored weekly for any acute changes and medication management and were not included…

    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 before2026-01-06 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews, and review of facility menus, the diet report and resident council minutes, the facility failed to ensure a well-balanced meal was served at lunch on 12/25/25 and the menu changes were approved by the dietitian. This affected one resident (#2) of three residents (#2, #18 and #37) reviewed for food service. The facility census was 61. Findings include: Review of the medical record for Resident #2 revealed an admission date of 04/29/23. Diagnoses included osteoarthritis, depressive disorder, congestive heart failure, and anxiety. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required set up and clean up help with eating. Review of the diet type report dated 12/05/25 revealed Resident #2 received a regular diet. Interview on 12/29/25 at 9:38 A.M. with Resident #2 revealed the food was not nutritional, lunch on 12/25/25 was four ounces of chicken noodle soup and applesauce. Resident #2 stated they get…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility investigation, and interview the facility failed to maintain a safe environment to prevent accidents for Resident #44. This affected one resident (#44) of three resident reviewed for accidents. The facility census was 54. Findings include: Review of Resident #44's medical record revealed an admission date of 05/02/24 with diagnoses including paraplegia, traumatic brain injury, suicidal ideations, transsexualism, suicidal behavior, conversion disorder with seizures, cognitive communication deficit, major depressive disorder, post-traumatic stress disorder (PTSD), and borderline personality disorder. Review of Resident #44's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. She required setup or clean up help with eating, oral hygiene, substantial to maximal assistance with toileting hygiene, dressing, personal hygiene, showers, and bed mobility. Transfers were completed with the use of the Hoyer (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 · F2024-06-18 · 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 observation, interview, record review, and facility policy review the facility failed to maintain enhanced barrier precautions (EBP) and transmission-based precautions (TBP) appropriately as required. This affected nine residents (#2, #4, #12, #15, #21, #24, #39, #49 and #55) and had the potential to affect all 56 residents residing in the facility. Findings include: Observation on 06/17/24 at 8:20 A.M. during a facility tour revealed the following: • An EBP sign was posted at the entrance of Resident #2's room. There was a storage bin to the left of the entrance door which held personal protective equipment (PPE). Next to the PPE storage bin placed along the hallway wall were two large garbage containers, one for soiled linen and the other for infectious garbage lined with a red trash bag. • An EBP sign was posted at the entrance of Resident #4's room. There was no available PPE at or near the entrance for staff use with EBP. • A TBP sign which did not designate the type of precautions and an EBP sign were posted at the entrance of Resident #21's room. The storage bin…

    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 · E2024-06-18 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and facility policy review the facility failed to prevent significant medication errors for Residents #16 and #42 when medications were signed out from the controlled drug records without evidence of administering the medication on the medication administration record (MAR) and verifying the medication was being administered as ordered by the physician. This affected two residents (#16 and #42) reviewed for controlled drug administration and had the potential to affect 25 additional residents (#2, #6, #10, #12, #15, #18, #19, #21, #23, #24, #25, #27, #28, #29, #30, #31, #37, #39, #41, #44, #47, #48, #49, #52 and #56) who received controlled medications. The facility census was 56. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 07/08/21. Diagnoses included low back pain and chronic pain. Review of Resident #16's physician orders revealed an order dated 09/06/23 for oxycodone 10-325 mg (milligrams) (opioid pain medication) every eight hours as needed for moderate to severe pain and no more than two…

    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 before2024-06-18 · 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

    Based on observation, record review, and interview the facility failed to treat residents with dignity and respect by maintaining uncovered urinary catheter drainage bags in public view. This affected two residents (#15 and #37) of six residents with urinary catheters. The facility census was 56. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 06/06/24. Diagnoses included chronic respiratory failure, chronic kidney disease stage III, and obstructive and reflux uropathy. Review of the physician orders effective June 2024 revealed Resident #15 required routine urinary catheter related care daily. Observation on 06/17/24 at 8:20 A.M. revealed Resident #15 lying in bed with an uncovered urinary catheter drainage bag hanging on the bed frame facing the doorway which was visible from the hallway outside of the room. Observation on 06/17/24 at 8:58 A.M. revealed Resident #15 lying in bed with an uncovered urinary catheter drainage bag hanging on the bed frame facing the doorway visible from the hallway outside of the room. Interview at the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2024-06-18 · 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 interview, record review, and facility policy review the facility failed to report an allegation of misappropriation by medication diversion involving Residents #2, #16 and #42. This affected three residents (#2, #16 and #42) of four residents reviewed for abuse, neglect, and misappropriation. The facility census was 56. Findings include: Interview on 06/17/24 at 9:52 A.M. with Licensed Practical Nurse (LPN) #358 indicated gossip was circulating with facility staff about controlled medications being misused but denied knowledge of any details. Interview on 06/17/24 at 10:50 A.M. with the Director of Nursing (DON) confirmed an allegation was made by Registered Nurse (RN) #333 against an agency nurse, LPN #369, on 06/09/24. RN #333 reported feeling a couple of the controlled medication signatures were forged by LPN #369. Immediately LPN #369 was removed from the schedule and the facility worked with the pharmacy on an investigation. RN #333 submitted copies of controlled medication records which 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-18 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to obtain physician orders and provide sufficient care for an indwelling urinary catheter. This affected one resident (#37) of four residents reviewed for urinary catheters. The facility census was 56. Findings include: Observation on 06/18/24 at 8:36 A.M. revealed Resident #37 lying in bed with an uncovered urinary catheter drainage bag hanging on the bed frame facing the doorway visible from the hallway outside of the room. Review of the medical record for Resident #37 revealed an admission date of 06/13/24. Diagnoses included diabetes mellitus type II with chronic kidney disease, and benign prostatic hyperplasia without lower urinary tract symptoms. There was no evidence of a diagnosis or justification for use of an indwelling urinary catheter. Review of the physician orders for June 2024 revealed no orders to monitor, maintain, or care for a urinary catheter. Review of the medication and treatment administration records for June 2024…

    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 before2024-06-18 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and facility policy review, the facility failed to accurately document controlled drug administration for Resident #1 to prevent a potential significant medication error. This affected one resident (#1) of three residents reviewed for controlled drug administration. The facility identified 30 residents (#1, #3, #7, #8, #9, #10, #12, #14, #15, #16, #17, #23, #24, #26, #28, #35, #36, #39, #40, #41, #42, #43, #44, #45, #46, #48, #50, #54 and #55) who received controlled medications. The facility census was 55. Findings include: Review of the medical record for Resident #1 revealed an admission date of 01/11/24 with a diagnosis of chronic pain syndrome. Review of Resident #1's physician orders revealed an order dated 01/10/24 for morphine 15 milligrams (mg) (opioid pain medication) twice daily for pain, and an order dated 06/13/24 for morphine 15 mg every eight hours as needed (PRN) for pain. Review of the medication administration record (MAR) and controlled drug records (CDR) for Resident #1's morphine from 06/20/24 to 07/10/24 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-11-08 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview the facility failed to ensure the garbage/dumpster area was maintained in a clean and sanitary manner. This had the potential to affect all 58 residents residing in the facility. Findings include: Observation of the facility dumpster area with Dietary Manager (DM) #461 on 11/06/23 at 10:28 A.M. revealed a door of the dumpster was open. A mattress, chair, and two wood pallets were stacked beside the dumpster. DM #461 verified the findings at the time of the observation.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-08 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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 and interview the facility failed to maintain a clean and homelike environment for Residents #1, #2, #3, #5, #10, #11, #12, #14, #16, #18, #19, #20, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #45, #46, #48, #51, #53, #54, #55, #57, #58, #263 and #264. The facility census was 58. Findings include: Interview on 11/06/23 at 10:02 A.M. with family of Resident #18 stated the window blinds were old, broken, or bent. Throughout the facility the windows were dirty, and several walls required repair or painting. Observation of the environment during a facility tour on 11/08/23 at 8:32 A.M. revealed the following: • Resident #29's room had a large gouge in the lower wall underneath the light fixture. • The exit door adjacent to Resident #31's room, and the right hallway wall by Resident #31's entry door had multiple scuffs, chips in the paint, and deep scrapes in the material. • Doorway frames and entry room doors for the small and large activity areas, and for Residents #2, #11, #19, #29, #31, #38 and #51 had multiple…

    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 before2023-11-08 · 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 interview, record review, and review of the Self-Reported Incident (SRI) number (#)238223 the facility failed to ensure Residents #39 and #42 were treated with respect and dignity. This affected two residents (#39 and #42) of four residents reviewed for dignity and respect (#14, #27, #39 and #42). The facility census was 58. Findings include: Interview on 11/06/23 at 9:05 A.M. with Resident #39 reported an (unnamed) agency State Tested Nursing Assistant (STNA) pushed a tray cart into Resident #39 which caused a cut to the arm. The STNA had an attitude and complained about things. Review of the medical record for Resident #39 revealed an admission date of 08/25/21. Diagnoses included chronic obstructive pulmonary disease, cognitive communication deficit, lymphedema, anxiety disorder, rheumatoid arthritis, tracheostomy status, chronic respiratory failure, and morbid severe obesity due to excess calories. Review of the Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had…

    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 · F2021-10-28 · tag F0839 — widespread
    Employ staff that are licensed, certified, or registered in accordance with state laws.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and review of the personnel records, the facility failed to ensure the Social Service Designee was appropriately trained and supervised to provide medical behavioral services. This had the potential to affect all 39 residents currently residing in the facility. Findings include: Review of the personnel record for the Social Service Designee (SSD) #247 revealed he was hired on 07/01/21. The application indicated he had a two year degree in wildlife and worked in several occupations, most recently as a Patient Service Representative. The record consisted of training in resident rights, and abuse, but did not contain documentation of his job description. Interview on 10/27/21 at 10:23 A.M. with SSD #247 revealed he received one day of training on social work from the SSD from another facility and was told he would learn as he goes. He stated he was also told to get an LOC for new admissions as he was also the admissions coordinator. When staff asked him where the LOCs were documented he stated he wasn't sure what they were asking him because he thought LOC meant…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-10-28 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure one resident, who was dependent on a tube feeding as the sole means of nutritional support, received the tube feeding as ordered by the physician to meet their hydration and nutritional needs. This affected one (Resident #42) of four residents reviewed for nutrition. The facility census was 39 residents. Findings include: Review of the medical record for Resident #42 revealed an admission date of 09/03/21 with diagnoses which included heart disease, cancer of the larynx (throat cancer), dysphagia (difficulty swallowing), absence of part of digestive tract, ileostomy (portion of the small intestine removed with an opening through the abdomen) , encephalopathy (disease affecting the brain), acute respiratory failure with hypoxia (low oxygen), bacteremia (bacteria in the blood), and septic shock. Review of the hospital transfer orders for Resident #42 dated 09/03/21 revealed the resident was ordered to be NPO (he was to have nothing by mouth) and to have all of his nutritional needs met through his feeding tube (a tube…

    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 · E2021-10-28 · tag F0800 — pattern
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to serve food at the proper portion size to meet the residents' nutritional needs. This affected 38 out of 39 residents who received meals prepared in the facility kitchen. Resident #19 did not receive any foods by mouth. The facility census was 39 residents. Findings include: Observation 10/26/21 at 11:31 A.M. of the tray line revealed a serving spoon was going to be utilized for service. Dietary Manager (DM) #206 changed it to a 4 ounce spoodle and prepared two plates with four ounces of pasta [NAME]. DM #206 then portioned eight ounces of pasta [NAME] for the rest of the regular consistency diets. DM #206 had a four ounce number eight scoop for the puree consistency diets and served four ounces of pasta [NAME] on two plates, then served the proper portion for pureed pasta [NAME]. Further observation of trayline on 10/26/21 at 12:00 P.M. revealed that DM #206 had to prepare more pasta [NAME] after 21 residents were served. Interview at the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-10-28 · tag F0801 — pattern
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure Dietary Manager (DM) #206 met the minimum qualifications to serve as the director of food and nutrition services. This had the potential to affect 38 of 39 residents who received meals prepared in the facility kitchen. Resident #19 did not receive anything by mouth. The facility census was 39 residents. Findings include: Initial tour of the kitchen on 10/25/21 at 8:25 A.M. revealed DM #206 was the only dietary employee that morning due to staffing issues. Interview on 10/26/21 at 2:44 P.M. with DM #206 revealed he was asked to cover the management position while maintaining the role of cook. He stated he did not do the training to become a Certified Dietary Manager (CDM) and verified he was unqualified for the position. He stated he has been acting as cook, aide, and manager for at least a year. Interview on 10/26/21 at 3:06 P.M. with the Administrator verified DM #206 was unqualified as a CDM. The Administrator stated he had been in that position prior to her employment in March 2021. She verified DM #206 stated he…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-10-28 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure there was sufficient dietary staff to prepare resident meals and snacks, and to serve resident meals. This affected 38 of 39 residents who received meals and snacks from the kitchen. Resident #19 did not receive anything by mouth. The facility census was 39 residents. Findings include: Initial tour of the kitchen on 10/25/21 at 8:25 A.M. revealed Dietary Manager (DM) #206 was the only dietary employee that morning due to staffing issues. DM #206 stated the dietary aide was off due to COVID-19. Interview on 10/25/21 at 8:26 A.M. with DM #206 verified breakfast was late in being served. He stated there have been many meals that have been late due to staffing issues. Observation on 10/25/21 at 9:17 A.M. revealed the last food cart was delivered to the back hall of the 100 hall unit. Observation on 10/25/21 at 12:45 P.M. revealed the first food cart for lunch was delivered to the 100 hall unit. Interview on 10/26/21 at 2:44 P.M. with DM #206 revealed a dietary schedule was not available. He stated he 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-10-28 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure 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 on observation, interview, and record review, the facility failed to ensure a registered dietitian reviewed the menus for nutritional adequacy, and a standardized menu was followed for meal preparation. This affected 38 of 39 residents who received meals prepared in the facility kitchen. Findings include: Observation on 10/25/21 at 12:45 P.M. revealed the posted menu on the 100 hallway was dated July 19, 2021 through July 25, 2021. Interview with Dietary Manager (DM) #206 on 10/26/21 revealed he did not post the menus on the units consistently due to a lack of time related to dietary staffing. He stated he did not have access to the menus until after his food was ordered, stating the meals do not match the current menu at times. Interview on 10/27/21 at 9:04 A.M. with Diet Technician (DT) #249 revealed she was at the facility on most Fridays. She did not check to see if menus were posted. Interview on 10/27/21 at 3:35 P.M. with Registered Dietitian (RD) #250 revealed she has not been to the facility since her hire date in August 2021. She stated she does not check the menus or…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-28 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure resident condition changes were communicated to the physician, dietitian, and resident responsible parties. This affected one (Resident #42) of four residents reviewed for changes in condition. The facility census was 39 residents. Findings include: Review of the medical record for Resident #42 revealed an admission date of 09/03/21 with diagnoses which included heart disease, cancer of the larynx (throat cancer), dysphagia (difficulty swallowing), absence of part of digestive tract, ileostomy (portion of the small intestine removed with an opening through the abdomen) , encephalopathy (disease affecting the brain), acute respiratory failure with hypoxia (low oxygen), bacteremia (bacteria in the blood), and septic shock. Review of the weights recorded in the medical record for Resident #42 dated 09/06/21 revealed the resident weighed 137.4 pounds. Review of the plan of care for Resident #42 dated 09/09/21 revealed the resident had a tube feeding to assist in maintaining or improving nutritional status related 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-28 · 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 observations, record review, and staff interviews, the facility failed to ensure fall interventions were implemented and care planned. This affected two (Residents #15 and #292) of three residents reviewed for falls. The facility census was 39 residents. Findings include: 1. Medical record review for Resident #292 revealed an admission date of 10/19/21 with diagnoses including cardiovascular accident (stroke) and pain. Resident #292 did not have a baseline care plan available in her chart that should have been completed within 48 hours. Review of the nursing progress notes revealed Resident #292 had falls on 10/19/21 (two falls), 10/22/21, and on 10/25/21. The falls on 10/19/21 had fall interventions placed to assist in preventing future falls. However, the falls on 10/22/21 and 10/25/21 revealed the facility staff did not implement new interventions to prevent future falls. Interview on 10/26/21 at 2:00 P.M. with the Director of Nursing (DON) revealed the fall interventions for Resident #292 were to provide a low bed to the resident on 10/22/21, and a scoop mattress on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-28 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    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 interview and record review, the facility failed to ensure physician visits for the residents as required. This affected three residents (#15, #24 and #36) of three residents reviewed for primary care physician visits. The census was 39 residents. Findings include: 1. Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, hyperglycemia, obesity, dependence on renal dialysis, restless leg syndrome, muscle weakness, hypothyroidism, and dependence on supplemental oxygen. Review of physician progress notes revealed one physician visit dated 08/07/21. There were no additional physician visits available for review in the medical record since the previous annual survey dated 03/14/19. Interview on 10/28/21 at 10:23 A.M. with the Director of Nursing confirmed there was one physician visit dated 08/07/21 documented for Resident #15 in the medical record since 03/14/19. 2. Record review revealed Resident #24 was admitted to the facility on [DATE]…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-28 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    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 interview and record review, the facility failed to ensure psychosocial services were provided for the residents. This affected two (Residents #14 and #39) of eight residents reviewed for psychosocial services. The facility census was 39 residents. Findings include: 1. Resident #14 was admitted to the facility on [DATE] with diagnosis of morbid obesity and acute respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact, and had feelings of depression, hopelessness, and feeling down. The resident was documented as overeating and had trouble concentrating on things like the newspaper and watching TV. The resident rejected care and assessments. Review of the progress notes revealed on 06/02/2021 the resident was irritable and much one-on-one with nursing staff was ineffective. Nursing spoke to social services about concerns and social services indicated they would speak with the resident. There was no documentation that this…

    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 · D2021-10-28 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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 interview and record review the facility failed to ensure psychosocial services were provided for the residents This affected three (Residents #14, #24, and #39) of eight residents reviewed for behavioral and emotional services. The facility census was 39 residents. Findings include: 1. Resident #14 was admitted to the facility on [DATE] with diagnosis of morbid obesity and acute respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact, and had feelings of depression, hopelessness, and feeling down. The resident was documented as overeating and had trouble concentrating on things like the newspaper and watching TV. The resident rejected care and assessments. Review of the progress notes revealed on 06/02/2021 the resident was irritable and much one-on-one with nursing staff was ineffective. Nursing spoke to social services about concerns and social services indicated they would speak with the resident. There was no…

    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

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to AOM HEALTHCARE — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.7+0.3 vs chain
Health inspection 3 of 52.3+0.7 vs chain
Staffing 1 of 51.6-0.6 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 19 homes this chain runs (chain average 2.7★, 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 / managerTypeRoleShareSince
POINTE WOODS INVESTMENT LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/01/2017
GOLDSTEIN, JEFFERYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST33%since 04/01/2017
SHERMAN, ALEXANDERIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL33%since 04/01/2017
SHERMAN, SAMUELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL33%since 04/01/2017

CMS files one row per role, so the 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$6.7M
Net patient revenuemost recent cost report
-8.7%
Operating marginrevenue minus expenses
$843K
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 8%Other / private 18%

About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $843K paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

$331per resident / day
operating cost
$10,064per month
≈ monthly operating cost
$305per 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 365441. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-06, 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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